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VOGEES SCALE OF URINE TINTS 



PRACTICAL URANALYSIS 



AND 



URINARY DIAGNOSIS. 



A Manual for the Use of Physicians, Surgeons, 
and Students. 



CHARLES Wf PURDY, M.D., 

QUEEN'S UNIVERSITY. 

Fellow of the Royal College of Physicians and Surgeons, Kingston ; Professor of Urology 

and Urinary Diagnosis at the Chicago Post-Graduate Medical School. Author of 

"Bright's Disease and Allied Affections of the Kidneys"; also of 

"Diabetes: Its Causes, Symptoms, and Treatment." 



SECOND EDITION. 



WITH NUMEROUS ILLUSTRATIONS, INCLUDING PHOTO- 
ENGRAVINGS AND COLORED PLATES. 




PHILADELPHIA: 

THE F. A. DAVIS CO., PUBLISHERS 

LONDON: 

F. J. REBMAN. 
1895. 





-0. 



6'3 



tff. 



COPYRIGHT, 1894, 



THE F. A. DAVIS COMPANY. 



[Registered at Stationers' Hall, London, England.] 



Philadelphia, Pa., U.S.A.: 

The Medical Bulletin Printing- House, 

1916 Cherry Street. 



r 



A 



TO THE 

PROFESSORS, PAST AND PRESENT ; 

TO THE 

FELLOWS, ALUMNI, AND STUDENTS, 

OF MY 



ALMA MATER, 



THE FOLLOWING PAGES ARE 

AFFECTIONATELY INSCRIBE!? 

BY 

THE AUTHOR. 



PREFACE. 



T)ur present knowledge of the urine and of diseases of the 
urinary organs may be said to be altogether abreast with other 
departments of scientific and practical medicine. At present, 
however, this knowledge is only accessible to the student 
through somewhat extended search through general works on 
Medicine, Surgery, Pathology, Plrysiological Chemistry, Mi- 
croscopy, etc., in addition to the various works devoted to this 
special subject. European writers, — especially those in our lan- 
guage, — following the sharp division between medical and sur- 
gical diseases, have invariably considered the present subject, 
both in general and special works, either from an exclusively 
medical or surgical point of view, and American writers thus far, 
without exception, have followed this example. But in America 
the whole profession is taught and qualified to practice both medi- 
cine and surgery, and, therefore, the above-mentioned custom 
compels the student, in order to gain a complete knowledge of 
this subject, to study several authorities, entailing increased 
expense and time, if not, indeed, confusion. Believing, therefore, 
that American authors should, so far as is possible, deal with 
the whole subject comprised in the titles of special works, it has 
been the aim of the author in the present work to furnish the 
student, physician, and surgeon, in one moderate-sized volume, 
the essential features of our knowledge of the urine and urinary 
diagnosis, thoroughly up to date, and in the most systematic, 
practical, and concise form. In carrying out this object an 
effort has first been made to bring out prominently the relations 
of the chemistry of the urine to physiological processes and 

(v) 



VI PREFACE. 

pathological facts. Thus, in dealing with normal urine, each 
constituent has been considered, so far as at present is known, 
in the following order : Its chemical nature and composition ; 
its source in the economy; the significance of its increase 
or decrease in the urine, with the relations of these to meta- 
bolic processes, food-supply, physical surroundings, and tend- 
ency toward disease; and, finally, the most approved methods 
of its detection and determination have been described. In 
dealing with abnormal urine each morbid constituent has been 
considered, so far as at present is known, in the following 
order: Its chemical nature and composition; its source in 
the econom}^ ; the clinical significance of its appearance in the 
urine ; and, lastl} T , the most approved methods of its detection 
and determination have been described. This method aims 
at teaching not only how to detect, isolate, and determine the 
constituents of the urine, normal and abnormal, but also to de- 
termine the presence of disturbed physiological processes, to 
detect the presence of pathological changes, and to measure the 
degree of both. 

The second division of the work — Urinary Diagnosis — aims 
at a concise description of the special features of the urine that 
indicate the presence of special pathological processes in prog- 
ress in the econom}", whether they be local or general, medical 
or surgical, together with a brief enumeration of the leading- 
clinical symptoms of each disease, and, in most cases, an 
epitome of their nature and etiology. 

Having compassed the whole text, it is designed that the in- 
vestigator will next be in a position to utilize the information 
therebjr furnished to the best practical diagnostic purposes, and 
give him the masteiy over the diseases considered,— /or, as a 
ride, he who has accurately diagnosticated disease, has already 
constituted himself its conqueror. 



PREFACE. Vll 

The author has freely quoted the views of standard authori- 
ties, endeavoring in all cases to make due acknowledgment of 
the same throughout the text. Should, however, any of the 
latter have been overlooked, he desires here to express his obli- 
gations for all knowledge derived from fellow-laborers in the 
same field of work. 

Some repetitions of matter will be noted, both in the text 
and foot-notes, the object being to save references to other parts 
of the work and render it more convenient as an open hand-book 
for the laboratory table. 

Over twenty-five 3 r ears' experience, coupled with a somewhat 
liberal examination of the literature of this subject, as well as 
considerable practical observation and experiment, have enabled 
the author to contribute some original matter and methods, 
which, he trusts, will prove to be an advance in certain practical 
departments of the subject. 

Finally, an appendix has been added upon the subject of 
urinary examinations for life-insurance. Believing, from some 
experience as a medical director, that on the one hand life-insur- 
ance associations are often unjustly called upon to pay insurance 
on uninsurable lives, and on the other hand that applicants are 
often deprived of the privileges of life-insurance to which they 
are justly entitled, especial pains have been taken with this de- 
partment of the work, with the earnest hope of contributing, in 
some degree, to the amelioration of these two forms of injustice. 

57 East Twentieth Street, 
Chicago, September, 1894. 



PREFACE TO SECOND EDITION. 



The demand for a second edition of this work within a few 
months of its first appearance renders it impossible to make 
extended additions to the text ; moreover, sufficient advances 
in our knowledge of the subjects therein considered have not 
been made within this brief interval to render such additions 
necessary. The very generous reception given the work by the 
medical press and profession, and its early adoption as a text- 
book by a large number of medical schools and colleges, have 
induced the author to thoroughly revise the work, to correct all 
discovered errors, and to further illustrate the text by additional 
colored plates. It is hoped that the additional labor expended 
in compassing these details may be accepted by the profession 
as a proof of the author's gratitude for the hearty reception of 
the work, as well as his earnest desire to make it more worthy 
of the praise it has received. 



57 East Twentieth Street, 
Chicago, July, 1895. 



(ix) 



CONTENTS. 



PART I.— ANALYSIS OF URINE. 

SECTION I. PAGE 

General Considerations • 1-20 

Composition of urine. Changes in the urine upon standing; alkaline 
fermentation, acid fermentation. Collection of urine for analysis. 

Physical characters of the urine : Color, variations of, in health ; 

pathologically. Vogel's scale of urine colors, application of scale ; 
Halliburton's table of color variations. Odor of the urine, variations 
of ; effects of drugs on ; clinical significance. Transparency of the 
urine, changes on standing, in disease. Consistence of the urine, 
normal, pathological. Specific gravity of the urine, variations of, in 
health ; pathological, prognostic significance ; determination of ; tem- 
perature of the urine, effects of, upon specific gravity. Chemical 
reaction of the urine, variations of; conditions affecting. Quantity 
of urine, average ; causes affecting, in health ; pathologically. Esti- 
mation of solids ; table for estimating from specific gravity ; signifi- 
cance of reduction of ; variations of, in disease ; rules in making 
deductions from estimation, average standard. 

SECTION II. 
Composition op Normal Urine 21-66 

Organic constituents : Urea, chemical characters of ; origin in the 
economy ; variations in quantity ; clinical significance of, sepa- 
ration from the urine ; detection. Determination, Liebig's method ; 
Rautenburg's and Pfluiger's modifications. Hypobromite method. 
Fowler's method of differential density. Uric acid, chemical nature 
of ; origin in the economy ; conditions affecting precipitation, daily 
average, detection. Determination, Hintz's method ; Haycraft's 
method ; Hopkin's method. Xanthin, chemical characters of, 
detection. Allantoin, chemical characters of, detection and de- 
termination. Creatinin, chemical characters of. Creatin, conditions 

affecting excretion, detection and determination of. Aromatic 

substances in the urine : Hippuric acid, chemical characters of, con- 
ditions affecting its excretion, detection and determination. Ethereal 
sulphates, origin of, circumstances causing excess of. Phenol-potas- 
sium sulphate (carbolic acid), detection and determination. Indoxyl- 
potassium sulphate (indican), clinical relations, detection, determi- 
nation. Urinary pigments : Normal urobilin, chemical characters 

of ; origin of, in the economy ; significance of variations ; detection. 
Uroerythryn, nature of. Urochrom, chemical characters of. Oxalic 
acid. Succinic acid. Lactic acid. Fatty acids. Glycero-phosphoric 
acid. Carbohydrates. Animal gum. Milk-sugar, detection of. In- 
osite, detection of. Ferments — pepsin, detection of ; diastase ; 

rennet ; trypsin. Mucin, detection of. Inorganic constituents : 

Chlorides, daily average, conditions affecting, clinical relations, de- 

(xi) 



XI I CONTENTS. 

PAGE 

tection, determinations. Phosphates — Total daily average, chemical 
characters, clinical relations, detection, determination. Earthy 
phosphates. Alkaline phosphates, quantitative determination of. 
Sulphates, amount, physiological relations, detection, determination. 
Carbonates, detection and determination of. Iron. Ammonium. 
Hydrogen dioxide. Gases— Carbonic acid, oxygen, nitrogen. Cen- 
trifugal analysis, advantages of. Method of estimating chlorides, of 
phosphates, of sulphates. 

SECTION III. 
Proteids . , 67-98 

Varieties of proteids in urine. Albuminuria, causes of ; clinical signifi- 
cance ; detection of albumin in the urine ; value of different tests ; 
method of testing for albumin in urine ; determination of albumin in 
urine. Proteoses, varieties of. Albumosuria— classification of albu- 
moses, chemical characters of, clinical significance, detection of. 
Peptonuria— mode of production of peptones, chemical nature of, 
clinical significance, detection, differentiation. Globulinuria — nature 
of globulin, clinical significance, detection and determination of. Dif- 
ferential testing for proteids. Halliburton's table of proteid reac- 
tions. Haemoglobinuria — nature of haemoglobin, clinical significance, 
detection. Fibrinuria — chemical nature of fibrin ; clinical signifii- 
cance of fibrinuria, detection. Mucinuria (pathological) — nature of 
mucin, clinical significance, detection of. 

SECTION IV. 
Carbohydrates 99-122 

Glycosuria— chemical nature of dextrose ; clinical significance ; detec- 
tion of sugar in the urine ; significance of sugar in the urine ; method 
of testing for sugar in the urine ; determination of sugar in the urine. 
Levulosuria— chemical nature of levulose ; clinical significance, detec- 
tion. Lactosuria— chemical nature of lactose ; clinical significance, 
detection. Inosituria— chemical characters of inosite ; clinical sig- 
nificance of inosituria; detection of inosite in urine. Glycuronic 
acid, chemical characters and relations ; significance of presence in 
urine ; detection. Cane-sugar, detection. Glycogen, chemical char- 
acters and relations. 

SECTION V. 
Abnormal Urine {continued) 123-146 

Ace tonuria— chemical characters of acetone ; clinical significance of ace- 
tonuria ; detection of acetone in urine. Diaceturia— chemical char- 
acters of diaceton ; clinical significance of diaceturia ; detection of 
diaceton. Choluria — bile-acids, significance of, in the urine ; detec- 
tion. Biliary pigments, significance of, in urine ; detection. Indoxyl- 
sulphuric acid, derivation of, in the system; clinical significance of, 
in urine; detection. Diazo reaction in urine, clinical significance 
of. Beta-oxybutyric acid, chemical charaters of ; detection in urine ; 
clinical significance. Ptomaines and leucomaines in urine, nature 
of. Putrescin. Cadaverin. Trimethylamin. Beatin. Jaksch's class- 
ification, detection, isolation, etc. Properties of animal bases. The 
urine as a toxin ; toxic properties of normal urine. Bouchard's ex- 
periments and conclusions. Toxicity of pathological urines. 



CONTENTS. Xlll 

SECTION VI. PAGE 

Urinary Sediments . 147-175 

Classification of urinary sediments. Sedimentation of urine, by gravity ; 
centrifugal method, advantages of; description of author's electric 
centrifuge. Deposits in urine upon long standing. Lithuria, nature 
of sediment ; clinical significance of uric-acid deposits. Urates, varie- 
ties of ; clinical significance. Oxaluria, microscopical characters of 
sediment ; differentiation, clinical significance. Beneke's conclusions 
as to causes of oxaluria. Phosphaturia— forms of phosphatic de- 
posits ; conditions favoring deposit ; clinical significance. Cystin- 
uria— microscopical character of cystin ; differentiation ; clinical sig- 
nificance. Leucinuria and tyrosinuria — chemical characters of leucin ; 
microscopical features. Tyrosin, chemical characters ; detection ; 
clinical significance. Melanuria ; chemical characters of melanin ; 
detection ; clinical significance. Lipuria, nature of ; clinical signifi- 
cance. 

SECTION" VII. 
Anatomical Sediments 176-212 

Hseinaturia, microscopical characters of blood ; clinical significance. 
Pyuria, character of urine in ; microscopical features of pus ; clinical 
significance ; detection of pus ; determination of pus and blood in 
urine. Epithelium, varieties found in urine ; microscopical features ; 
clinical significance. Urinary casts, nature and origin ; classifica- 
tion. Blood-casts, appearance of ; clinical significance. Epithelial 
casts, origin of ; appearance of ; clinical significance. Pus-casts. Bac- 
terial casts, appearance and significance of. Granular casts, varieties 
found ; appearance and characters ; clinical significance. Fatty 
casts, origin of ; clinical significance. Hyaline casts, appearance of ; 
varieties, origin, clinical significance. Cylindroids, appearance of ; 
clinical significance of. Method of searching for casts ; obstacles 
formerly encountered overcome by centrifugal methods ; precautions 
in microscopical examination. Spermatozoa, appearance, nature, 
clinical significance of deposit. Fragments of tumors, diagnostic 

value. Bacterimia, classification. Non-pathogenic fungi, varieties 

of ; microscopical features of ; significance of. Ammoniacal bacteri- 
uria. Pathogenic fungi, varieties of, in urine,— bacillus tuberculosis, 
gonococci, etc. Vermes: Distoma haematobium, nature of ; result- 
ing lesions ; clinical symptoms. Filaria sanguinis hominis, appear- 
ance, nature, and habits of ; resulting lesions. Echinococci, features 
of. Strongylus gigas, description of. 

SECTION VIII. 
Gravel and Calculus • 213-228 

Classification. Composition. Causes of urinary concretions. Uric-acid 
concretions, frequency of, recognition of, conditions favoring origin 
and growth. Urate concretions, nature, frequency in infancy, Cal- 
cium-oxalate concretions, nature. Cystin calculus, nature, oi'igin. 
Xanthin concretions, nature, origin, recognition. Calcium-phos- 
phate concretions, nature. Ammonio-magnesium-phosphate concre- 
tions, origin, significance. Mixed phosphatic concretions, nature, 
origin. Calcium-carbonate concretions, nature. Fatty concretions. 



CONTENTS. 



Indigo concretions. Fibrin and blood concretions. Prostatic con- 
cretions. Clinical differentiation. Analysis of calculi— physical 
characters, section, heat, chemical analysis, microscopical features, 
etc. Characteristics of uric acid, xanthin, cystin, protean concre- 
tions, urostealith, urates of fixed alkalies, calcium oxalate, ammonio- 
magnesium phosphate. Heller's table for analysis of calculi. 



PART II.— URINARY DIAGNOSIS. 

SECTION IX. 

Diseases of the Urinary Organs and Urinary Disorders . 231-265 

Regional anatomy of the kidneys and renal pelvis, the ureters, the 
bladder. Physical examination of the kidneys. Palpation, percussion, 
etc., of the ureters, of the bladder. Cystoscopic exploration. Diag- 
nosis. Acute renal hyperaemia, nature of, the urine in ; clinical 
features of. Passive renal hyperaemia, nature, causes, urine in ; 
prominent clinical features of. Acute diffuse nephritis, nature, 
causes, urine in ; leading clinical features of. Cbronic diffuse 
nephritis, nature, causes, urine in ; leading clinical features of. 
Chronic interstitial nephritis, nature and causes of; the urine in ; 
leading clinical features. Amyloid disease of the kidneys, nature 
and causes of ; the urine in ; differential features of urine ; leading 
clinical features. Cystic disease of kidneys, urine in, etc. 

SECTION X. 

Diseases op the Urinary Organs and Urinary Disorders 

(continued} 266-312 

Renal tuberculosis, nature, causes, etc. ; the urine in ; leading clinical 
symptoms. Renal cancer, the urine in ; prominent clinical symptoms 
of. Renal calculus, the urine in; clinical symptoms. Renal em- 
bolism, nature, causes, frequency, etc. ; the urine in ; prominent 
clinical symptoms of. Uraemia, nature, causes of ; the urine in ; 
prominent clinical features of. Haemoglobinuria, nature and causes ; 
the urine in ; leading clinical symptoms. Chyluria, nature and 
causes ; the urine in ; leading clinical symptoms. Diabetes insipidus, 
nature and causes ; urine in; leading symptoms. Diabetes mellitus, 
nature, causes ; the urine in ; leading clinical symptoms. Urinary 
fever, nature and causes ; the urine in ; leading clinical symptoms. 
Hydronephrosis, nature and causes ; the urine in ; leading symptoms. 
Pyonephrosis, nature and causes ; the urine in ; prominent symptoms. 
Acute interstitial nephritis, nature and causes ; the urine in ; promi- 
nent symptoms. Chronic pyelitis, nature and causes ; the urine in ; 
clinical symptoms of. Movable kidney, nature and causes ; the urine 
in ; prominent clinical features of. Cystitis, nature and causes ; the 
urine in ; leading clinical symptoms. Stone in the bladder, causes ; 
the urine in; prominent clinical features. Tuberculosis of the 
bladder, origin and nature ; the urine in ; leading clinical features. 
Cancer of the bladder, origin ; the urine ; leading clinical features. 
Benign growths in the bladder, nature, causes ; the urine in ; leading 
clinical features. 



CONTENTS. XV 

SECTION XI. 

PAGE 

The Urine in Other Diseases 313-331 

Simple pyrexia. Acute infectious diseases : Typhoid fever ; scarlatina ; 
cholera ; diphtheria ; variola ; yellow fever ; typhus fever. Diseases 
of the liver : Cirrhosis ; jaundice ; acute yellow atrophy. Articular 
diseases : Rheumatism ; acute gout. Diseases of the nervous sys- 
tem : Epilepsy ; hysteria ; meningitis. Diseases of the respiratory 
organs: Pulmonary tuberculosis ; pneumonia; acute pleurisy; acute 
bronchitis. Diseases of the digestive system : Dyspepsia, etc. 

APPENDIX. 
Examination op Urine for Life-Insurance 333-349 

Physical examination of urine : Color, transparency, specific gravity, 
reaction, indications of variations. Chemical examination : Albu- 
min, method of testing for ; differentiation ; significance ; dangers to 
be avoided in accepting albuminuric applicants. Sugar, testing for 
significance of ; dangers of accepting glycosuric applicants. Urea, 
quantitative determination of. Microscopical examination of the 
urine : Suggestions on searching for casts ; morphological elements, 
etc., when difficult to find. Pyuria, dangerous features of. Hsema- 
turia, relations of, to insurance. Calculi, relations of, to insurance. 
Rules as guides for medical examiners. 



LIST OF ILLUSTRATIONS. 



PAGE 

Frontispiece. 



Plate I. Vogel's scale of urine tints. (Colored.),' 

Plate II. (Colored.), 

1. Squibb 's urinometer, 

2. Crystals of urea, 

3. Dr. Doremus's ureometer, 

Plate III. (Colored.), 

4. Uric-acid crystals. (After Kuhn.), 

5. Creatinin crystals. (After Kuhn.), ....... 

6. Hippuric-acid crystals. (After Peyer.), 

7. Author's percentage tube, 

8. Esbach's albuminometer, .......... 

Plate IV. Crystals of phenylglucosazone. (After v. Jaksch. Colored.), 

9. The author's apparatus for quantitative determination of sugar in 

urine, ~ . 

10. Ultzmann's polarizing saccharimeter adjusted to microscope-stand, 

11. Sectional view of Ultzmann's polarizing saccharimeter, . 

12. The author's electric centrifuge. (One-fourth actual size.), . 

13. The author's sediment tubes for centrifugal sedimentation. (Full size.) 
Plate V. Uric-acid crystals with amorphous urates. (After Peyer 

Colored.), 

14. Sodium-urate crystals. (After Peyer.), .... 
Plate VI. Ammonium urate, showing spherules and thorn-apple 

shaped crystals. (After Peyer. Colored.),. 

15. Various forms of calcium-oxal ate crystals. (After Peyer.), 

16. Triple-phosphate crystals. (After Ultzmann.), 

17. Calcium-phosphate crystals. (After Peyer.), 

18. The more common form of cystin crystals. (After Peyer.), 

19. Leucin and ty rosin. (After Peyer.), 

20. Normal blood-corpuscles. (After Peyer.), 

21. Pus-corpuscles. (After Ultzmann.) 

22. Epithelium from various parts of the urinary tract. (After v 

23. Epithelial casts. (After Peyer.), 

24. Granular casts. (After Peyer.), 

25. Fatty casts. (After Peyer.), 

26. Narrow hyaline casts. (After Peyer.), .... 

27. So-called waxy casts. (After Peyer.), .... 

28. False casts. (After Peyer.), 

29. Spermatozoa in urinary sediment. (After Peyer.), 

30. Yeast-fungus in urine. (After Harley.), 

(xvii) 



Jaksch.) 



13 
21 
28 
30 
31 
38 
40 
64 
82 
105 

111 
114 
115 
149 
151 

154 

158 

159 
161 
164 
165 
169 
171 
176 
180 
185 
189 
191 
192 
193 
194 
196 
199 
201 



XV111 LTST OF ILLUSTRATIONS. 

FIG. PAGE 

31. Micrococcus urese. (After v. Jaksch.), 202 

Plate VII. Tubercle bacilli in urinary sediment. (After v. Jaksch.), . 204 

32. Eggs of distoma from urinary sediment, 206 

33. Distoma haematobium, male and female, with eggs, .... 207 

34. Filaria in human blood. (After Mackenzie.), 208 

35. Echinococcus, with two hooklets and section of cystic membrane greatly 

magnified. (After Peyer.), 210 

36. Topographical relations of kidneys, anteriorly. (After Morris.), . . 233 

37. Topographical relatious of kidneys, posteriorly. (After Morris.), . 234 

38. Relations of the kidneys. ( After Sappey .) , 235 

39. Urinary sediment in passive hypersemia of the kidneys. (After Peyer.), 245 

40. Urinary sediment in acute nephritis. (After Peyer.), .... 250 

41. Urinary sediment in chronic diffuse nephritis, showing results of fatty 

changes in progress. (After Peyer.), 253 

42. Waxy casts in urine of amyloid disease of the kidney. (After Peyer.), 261 

43. Urinary sediment in pyelitis . (After Peyer.), 297 

44. Urinary sediment in cystitis. (After Peyer.), 303 



Part I. 

Analysis of Urine. 



GENERAL CONSIDERATIONS. 

THEORIES OF SECRETION AND EXCRETION OF URINE. 

COMPOSITION OF NORMAL URINE. 

ABNORMAL URINE. PROTEIDS. 

CARBOHYDRATES. 

URINARY SEDIMENTS. 

CHEMICAL SEDIMENTS. 

ANATOMICAL SEDIMENTS. 

GRAVEL AND CALCULUS. 



SECTION I. 

GENERAL CONSIDERATIONS. 

The recent advances in our knowledge of physiological chem- 
istry, with the more extended and refined use of the microscope, 
have lent great precision to the study of the composition of the 
urine, and thereby furnished us with a keener insight into the 
relationship of the urine to the organism, both in health and in 
disease. The variations in nutrition and waste are accurately 
recorded in the urine hour by hour, and by an intelligent inter- 
pretation of modern methods of uranalysis these physiological 
tides may now be read as accurately as we can number the pulsa- 
tions of the heart. By the same methods we are now enabled to 
measure the hourly inroads upon the organism made by disease 
with a precision often greater than is afforded by the pulse or 
the clinical thermometer. Wherever in the economy pathogenic 
processes seriously disturb nutrition or normal metabolism, the 
results are recorded in the urine, because the urine, more emi- 
nently than any other excretion, represents the equation of these 
changes. 

The accurate study of the urine, therefore, has become one 
of the essential features in advanced clinical medicine. Indeed, 
through uranalysis alone can an almost daily increasing number 
of diseases be determined, their intensit}' be gauged, and their 
progress toward recovery, or their tendency toward a fatal ter- 
mination, be predicted. While it is impossible to diagnosticate 
all diseases from the urine, it is, nevertheless, true that no seri- 
ous disease can be in progress in the economy without giving 
rise to more or less marked changes in the character of the urine, 
and therefore we can no longer afford to exclude urinary analysis 
from the scientific investigation of any serious form of disease. 

In order to fully comprehend the relations of the urine to 
the organism under the influence of the various pathological 
conditions, it is first necessary to become acquainted with the 

(i) 



2 ANALYSIS OF URINE. 

physiology of secretion and excretion of the urine, as well as 
the normal composition of the latter, together with those fluct- 
uations which are included within the range of health. 

While a number of points in the physiology of the secretion 
and excretion of the urine still remain undetermined, it may be 
stated that our present knowledge of the subject indicates that 
the process is partly a physical and partly a vital one. The 
older theory of Bowman, based on the anatomical construction 
of the kidne} T s, taught that the epithelial cells of the urinary 
tubules constitute the true secretory structure of the kidneys, 
while the glomeruli act as mere filters for the escape of the 
watery elements from the blood. According to Bowman, there- 
fore, the filtrate from the glomeruli consists almost solely of 
water, which aids in extracting the other constituents of the 
urine from the epithelium of the tubules in its passage along 
the latter. 

Ludwig, on the other hand, explains the process on purely 
physical grounds, basing his theory on the varying degrees of 
blood-pressure in the glomerular circulation and the interchange 
of constituents by diffusion or osmosis in the urinary tubules. 
Assuming that the relative blood-pressure in the kidney is great- 
est in the glomerular tufts in consequence of the resistance to 
the efferent circulation, Ludwig holds that, consequently, a free 
exudation of water takes place from the tufts, with, perhaps, 
some dissolved salts. This renders the blood much concentrated 
— thickened — when it reaches the capillary plexus surrounding 
the convoluted tubes, while within the latter is now the thin, 
aqueous filtrate from the tufts. It will be noted that such con- 
ditions form all the essential elements for active osmosis, — within 
the tubules thin, watery fluid, and in the surrounding capillaries 
thickened blood, while between them is interposed a thin mem- 
brane, — the tubular wall. An interchange of elements conse- 
quently occurs, by means of which water from the urinary tubules 
passes into the blood ; while, on the other hand, the products of 
retrograde tissue changes — urea and salts — pass from the blood 
into the tubules, mingling there with the thin fluid and consti- 
tuting the urine. 

Unfortunately for the theory of Ludwig, he leaves out of 



GENERAL CONSIDERATIONS. 3 

consideration any function on the part of the renal epithelium, 
which violates analogical reasoning, because the renal epithelium 
possesses the anatomical peculiarities of glandular epithelium, 
the function of which is secretory or selective wherever else met 
with throughout the economy. Moreover, both clinical and 
pathological experiences teach that the renal epithelium pos- 
sesses a distinct and important function in the elaborating proc- 
esses of the kidney ; for, in diseases which destroy or remove 
this epithelium from the urinary tubules, urea and allied prod- 
ucts are retained in the system, and the phenomena of uraemia 
is evoked. Finally, the interesting experiments of Heidenhain 
have conclusively proved that the renal epithelium possesses a 
distinct selective power, as follows : If a slightly-concentrated 
solution of indigo-sulphate of sodium be injected into the blood 
of an animal, a blue color will soon after be communicated to the 
urine and the epithelium of the convoluted tubules and ascending 
limbs of Henle's tubes, while the Malpighian structures do not 
present the slightest trace of blue. If the spinal cord of an 
animal be first divided and the indigo injection be subsequently 
made, the following phenomena may be observed: No urine 
whatever reaches the bladder, but the blue color passes into the 
kidney and may be seen in the convoluted tubes and ascending 
limbs of Henle's tubes as before. Ten minutes after the injec- 
tion the coloring matter is found solely in the epithelial cells in 
the locations above noted. An hour after the injection the epi- 
thelial cells are found colorless, the blue matter having passed 
into the lumens of the tubes, where, in the absence of water from 
the glomeruli, it concentrates into crystals. This establishes a 
distinct eliminative power on the part of the renal epithelium 
altogether independent of the glomeruli, because the latter were 
paralyzed by section of the spinal cord. 

It seems altogether likely, therefore, that the chief specific 
principles of the urine are eliminated by the renal epithelium, 
precisely as are the coloring matters in Heidenhain 's experi- 
ments. This seems the more probable now, since it is pretty 
well established that the chief urinary constituents — urea, uric 
acid, etc. — exist preformed in the blood. Our present knowledge 
on this subject warrants the conclusion that the production of 



4 ANALYSIS OF URINE. 

the urine is chiefly an elaborating or secreting process, regulated 
in its fluidity b}' the glomerular system. In other words, that 
the water and some of the salts are secreted by the glomeruli, 
the peculiar anatomical construction of which permits a varying 
degree of activity corresponding chiefly with the varying degrees 
of blood-pressure and blood-fluidity ; while, in the main, the solid 
excretory products of the urine are eliminated by the epithelium 
of the renal tubules, through their vital, selective, or secretory 
power, as in all other glandular structures of similar anatomical 
construction. 

Composition of the Urine. — The constituents of normal urine 
are derived from the elements of retrograde tissue metamorphosis 
in the healthy state of the organism, together with certain waste 

Amounts of Urinary Constituents Passed in Twenty-Four Hours. 



Constituents. 



Weight, 66 Kilo- 
grammes. 



Per Kilogramme of 
Body-Weight. 



Water 

Total solids 

Urea 

Uric acid 

Hippuric acid 

Creatinin 

Pigment and other organic matters 

Sulphuric acid 

Phosphoric acid 

Chlorine 

Ammonia 

Potassium 

Sodium 

Calcium 

Magnesium 



1500.00 grammes. 

72.00 " 

33.18 " 

0.55 " 

0.40 " 

0.91 " 

10.00 " 

2.01 " 

3.16 " 
7-8.00 

0.77 " 

2.50 " 

11.09 " 
0.26 

0.21 " 



23.000 grammes. 

1.100 " 
0.500 

0.008 " 

0.006 " 

0.014 " 

0.151 " 

0.030 " 

0.048 " 

0.126 " 



products of substances introduced into the system in the form of 
food and beverages. The normal constituents of the urine, ac- 
cording to the basis of classification adopted by Hoppe-Seyler, 
are as follow : 1. Urea and related substances, — uric acid, allan- 
toin, oxaluric acid, xanthin, guanin, creatinin, thio- (sulpho-) 
cyanic acid. 2. Fatty and other non-nitrogenous substances, — 
fatty acids of the series C n H2 U 02 ; oxalic, lactic, glycero-phos- 
phoric acids ; very small quantities of certain carbohydrates — 
sugar (Brucke). 3. Aromatic substances, — the ethereal sulphates 
of phenol, cresol, pyrocatechin, indoxyl, and skatoxyl ; hippuric 



GENERAL CONSIDERATIONS. 5 

acid, aromatic ox}^acids. 4. Other organic substances, — pig- 
ments ; ferments, especially pepsin ; mucus, and humous sub- 
stances. 5. Inorganic salts, — chlorides of sodium and potassium, 
potassium sulphate; sodium, calcium, and magnesium phos- 
phates; silicic acid, ammonium compounds, and calcium carbo- 
nate. 6. Gases, — nitrogen and carbonic acid. 

The quantitative composition of the human urine is best ex- 
pressed in the classical table of Parkes, as on' preceding page. 

The proportion between the solids of the urine and the water, 
according to Becquerel, is as follows : Water 967 grains, solids 
33 grains in each 1000 grains. Of the solid matters the organic 
elements amount to about 24.865 grains, while the inorganic con- 
stituents are about 8.135 grains in each 1000 grains. 

Changes in the Urine upon Standing. — Considering the some- 
what complex composition of the urine, holding as it does in so- 
lution both organic and inorganic compounds which are subject 
to organic as well as chemical alterations, as might be expected, 
the urine is subject to more or less rapid changes after it has 
been voided. The rapidity of these changes depends chiefly upon 
the reaction and concentration of the urine, the temperature of 
the room in which it is kept, and the degree of access to micro- 
organisms. A normal acid urine usually first precipitates the 
amorphous urates, then uric acid, and frequently oxalate of cal- 
cium. Under ordinary circumstances these changes take place 
within three daj^s after the urine is voided. At ordinary tem- 
peratures (70° to 74° F.— 21.1° to 23.3° C), after twenty-four 
to forty-eight hours' standing, and much sooner under high tem- 
peratures (say, 100° F. — 37.8° C), the urine begins to become 
dull and opaque from the presence of micro-organisms, — fission 
fungi. These multiply, and at the end of four or five days, as a 
consequence, ammoniacal decomposition sets in; that is to sa} T , 
through the activity of the fungi the urea is gradually trans- 
formed into carbonate of ammonium. The urine becomes more 
and more alkaline from the liberation of ammonium carbonate. 
The amorphous urate deposit now becomes transformed into 
urate of ammonium, uric-acid crystals are substituted by char- 
acteristic prismatic ciystals of ammonio-magnesian phosphate 
(triple phosphate), and amorphous granules of calcium phosphate 



b ANALYSIS OF URINE. 

are deposited in quantity at the bottom and sides of the vessel. 
Finally, the bacterial activity diminishes as the urine becomes 
strongly alkaline, and the micro-organisms ultimately perish. 
Urines of low density and feeble acidity undergo the above-de- 
scribed changes more rapidly, and, moreover, as a rule, do not 
deposit urates. 

A change sometimes occurs in acid urine, consisting of pro- 
gressive acidit}^, in which the urine darkens in color and deposits 
uric acid and urates and sometimes calcium-oxalate crystals, with 
the frequent presence of yeast-fungus and bacteria. This was 
formerly termed the " acid fermentation, 11 but, according to 
Scherer, it is caused by the mucus, which acts as an enzyme, or 
ferment, producing an acetic-acid or lactic-acid fermentation, with 
precipitation of uric acid and acid urates. 

Collection of Urine for Analysis. — For the purpose of quanti- 
tative determination of the urinary constituents it is essential 
to have a sample of a mixture of the whole product of the kid- 
neys for twenty-four hours. The varying degrees of solid and 
fluid contents of the urine at different hours of the day render 
the observance of the above rule strictly essential if we desire a 
sample of urine that will represent the average product of the 
kidneys. In order to guard against the early changes in the 
urine which have just been described, the urine should be col- 
lected in a perfectly-clean vessel, — preferably a half-gallon bottle, 
— which should stand in a cool but dry room during the collec- 
tion, and the bottle should be corked after each addition of urine. 

For qualitative determination of the morbid products of the 
urine — as sugar, albumin, etc. — it is preferable to collect a freshly- 
voided sample of the urine about three hours after a meal, not the 
urine voided in the morning on rising. Of all urines, that Avoided 
in the morning on rising is the least likely to contain albumin 
or sugar. When these substances are only occasionally present 
in the urine, the}' are most likely to be found after food and ex- 
ercise. Finally, in collecting a sample of urine for purely micro- 
scopical examination, it should be perfectly fresh and as con- 
centrated as possible. It has been shown that the urine soon 
undergoes ammoniacal changes upon standing, the result of which 
is to render it more or less strongly alkaline. Now, morphological 



PLATE II. 




Sediment of Alkaline Fermentation. (After Hoffman 
and Ultzmann.) 



PHYSICAL CHARACTERS OF THE URINE. 7 

elements, as epithelium and casts, are soluble in alkaline solu- 
tions ; so that they may, if present when the urine is voided, be- 
come unrecognizably altered, or even disappear, if the foregoing 
precautions be not observed. Concentration of the urine may be 
obtained by directing the patient to abstain, as much as consistent 
with comfort, from the use of fluids for twenty-four hours. 

PHYSICAL CHARACTERS OF THE URINE. 

Color. — The average color of normal urine of specific gravity 
1020 and 1500 cubic centimetres' volume for twenty-four hours 
is straw or wine yellow, — amber-colored. This, however, is sub- 
ject to considerable variations at different times of the day, and 
under varying circumstances included within the range of perfect 
health. Thus, from an almost colorless (watery) appearance the 
urine may range through the yellows and reach reddish brown. 
The pale, watery urine in health contains relatively small amounts 
of coloring matter, as well as urea and salts. It is seldom very 
acid, often neutral or feebly alkaline, and it is most often brought 
about by copious drinking. Highly-colored urine, on the con- 
trary, is usually concentrated, containing relatively large quan- 
tities of solids and coloring matters. Its specific gravity is high, 
and its reaction is usually sharply acid. It results from dimin- 
ished excretion of water by the kidneys, while the solids and 
coloring matters are normal or increased. In health it may 
occur after hearty meals, vigorous exercise, or when the skin 
has been unduly active and little fluids imbibed. 

Pathologically the urine is subject to much wider variations 
in color than in health. This may be due either to increase or 
diminution of the normal coloring matters, on the one hand, or, 
on the other, to the addition of abnormal pigments. Abnor- 
mally light-colored urine is often due to polyuria, as in diabetes, 
hysteria, and convulsions ; or it is often observed in diseases of 
the kidney which not only increase the normal amount of water 
in the urine, but which also reduce the solids and coloring mat- 
ters, — notably, interstitial nephritis and anryloid degeneration 
of the kidnej^s. Highly-colored urine, approaching red, is most 
often induced b}^ acute pyrexia and inflammations. This is due 
in part to concentration of the urine, though largely also to the 



ANALYSIS OF URINE. 



presence of uro-erythrine. The distinctly red tints of the urine 
are always due to the presence of foreign coloring matters, most 
often blood. The dark-brown tints may be due to the presence 
of methsemoglobin in diseases of the kidney attended by haem- 
orrhage. The urine in cases of melanotic cancer sometimes be- 
comes almost black, especially after standing for some time. 
Green urine, of dull hue, is common in jaundice, the color being 
due to the presence of biliverdin. The urine is frequently of a 
greenish hue in diabetes, notably when the urine contains a high 
percentage of sugar. Blue urine, of dull tint, is not uncommon 
in cholera and typhus, owing to the presence of indigo. Finally, 
certain drugs, when swallowed, affect the color of the urine to 
a more or less marked degree : thus, rhubarb and senna cause 
brown or reddish tints ; carbolic acid sometimes causes a black 
color in the urine, notably after the urine has stood some time ; 
the same results follow the ingestion of naphthalin, hydrochinon, 
resorcin, and pyrocatechin. Lastly, santonin, when swallowed, 
always causes a yellow color in the urine, of decided hue. 

J. Yogel has, at considerable labor, constructed a scale of 
colors of the urine from nature, which has, in a manner, become 
standard for comparative purposes. These colors he expresses 



I 


II 


III 


IV 


V 


VI 


VII 


VIII 


IX 




1 


2 

1 


4 

2 
1 


8 
4 
2 

1 


16 
8 
4 
2 
1 


32 
16 
8 
4 
2 
1 


64 
32 
16 
8 
4 
2 
1 


128 

64 

32 

16 

8 

4 

2 

1 


256 

128 

64 

32 

16 

8 

4 

2 

1 


Pale yellow = I 

Light yellow = 11 

Yellow = 111 

Reddish yellow . . . = IV 

Yellowish red = V 

Red = VI 

Brownish red = VII 

Reddish brown . . . .= VIII 
Brownish black. . .= IX 



as (1) pale yellow, (2) light yellow, (3) yellow, (4) reddish yel- 
low, (5) yellowish red, (6) red, (7) brownish red, (8) reddish 
brown, and (9) brownish black. (See Frontispiece.) He divides 
these into three groups, the first three being yellow urines, the 
second three reddish urines, and the last three brown or dark 
urines. In comparing the color of the urine with the scale the 
urine should first be filtered if not perfectly clear, and it should 



PHYSICAL CHARACTERS OF THE URINE. 9 

be examined by transmitted light in a glass vessel at least three 
or four inches in diameter. It is claimed that the shades of 
color in Yogel's scale correspond to certain relative amounts of 
coloring matter in the urine, and the test-table on preceding page 
has been constructed for the purpose of color analysis. 

Application. — The table indicates how much coloring matter 
equal parts of urine of different colors contain relatively. Thus, 
if a certain volume of pale-} r ellow urine contain 1 part of coloring 
matter, the same volume of yellowish red contains 16 parts; of 
red, 32 parts ; of brownish black, 256 parts. It further indi- 
cates that 1 volume of yellow urine contains as much coloring 
matter as 4 volumes of pale yellow ; 1 of red = 32 of pale yel- 
low, etc. If, therefore, one person pass 1000 cubic centimetres 
of yellow urine in twenty-four hours, and another 4000 cubic 
centimetres of pale-yellow urine in the same time, both secrete 
an equal amount of coloring matter. In order to make an ap- 
proximate comparison by figures, Vogel places the quantity of 
coloring matter which 1000 cubic centimetres of pale^ellow 
urine contain = 1. 

Example. — 1800 cubic centimetres of urine of yellow color 
are passed. 1000 cubic centimetres of pale-} r ellow urine equal 
one part of coloring matter. 

But yellow, according to the table, contains four times as 
much; therefore the following proportions: 1000:4 = 1800:^ 
= 7.2 as the amount of coloring matter in 1800 cubic centimetres 
of yellow urine, the coloring matter in 1000 cubic centimetres of 
pale-yellow urine being considered as the unit. 

Halliburton gives the following concise table of color vari- 
ations of the urine, with their causes. (See next page.) 

Odor. — The odor of normal freshly-voided urine is peculiar, 
— of slightly aromatic nature, — due, it is believed, to phenylic, 
taurylic, damoluric, and damolic acids in minute quantities. 
There is considerable difference in the intensity of the uric odor 
in health, always being most pronounced in concentrated urine. 
If the urine become alkaline from standing, it acquires a pecu- 
liar, repulsive, putrescent odor, in which ammonia is plainly 
distinguishable. The former is due to the decomposition of 
mucus and other organic matters, while the ammonia is in the 



10 



ANALYSTS OF URINE. 



Color. 


Cause of Coloration. 


Pathological Condition. 


Nearly colorless. 


Dilution, or diminution 
of normal pigments. 


Nervous conditions : 
hydruria, diabetes insipi- 
dus, granular kidney. 


Dark yellow to 
brown-red. 


Increase of normal, or occur- 
rence of pathological, 
pigments. 


Acute febrile diseases. 


Milky. 


Fat-globules. 


Chyluria. 


Pus-corpuscles. 


Purulent diseases of the 
urinary tract. 


Orange. 


Excreted drugs. 


Santonin, chrysophanic acid. 


Red or reddish. 


Unchanged haemoglobin. 


Haemorrhages, 
or haemoglobinuria. 


Pigments in food (logwood, 
madda, bilberries, fuchsin). 






Haematin. 


Small haemorrhages. 




Methaemoglobin. 


Meth aemoglobinuria. 


brown-black. 


Melanin. 


Melanotic sarcoma. 




Hydrochinon and catechol. 


Carbolic-acid poisoning. 


Greenish yellow, 
greenish brown, ap- 
proaching black. 


Bile-pigments. 


Jaundice. 


Dirty green 
or blue. 


A dark-blue scum on sur- 
face, with a blue deposit, 
due to an excess of indigo- 
forming substances. 


Cholera, typhus; seen es- 
pecially when the urine is 
putrefying. 


Brown-yellow to 
red-brown, becom 
ing blood-red upon 
adding alkalies. 


Substances which are in- 
troduced into the system 
with senna, rhubarb, and 
chelidonium. 





PHYSICAL CHARACTERS OF THE URINE. 11 

form of carbonate, resulting from bacterial decomposition of a 
part of the contained urea,— CON 2 H 4 -j-2H 2 = (NH 4 )2C0 3 . 

Certain substances, when ingested, impart to the urine pecu- 
liar and unnatural odors. Thus, a characteristic odor is acquired 
after eating asparagus, and an odor not unlike violets is produced 
by the administration of turpentine-oil. The odor of cubebs, 
copaiba, sandalwood-oil, garlic, tolu, etc., are more or less com- 
municated to the urine when taken internally. These odors may 
be serviceable by indicating that the patient has taken certain 
medicines or foods. Beauvis and others have claimed that the 
peculiar odors after asparagus and turpentine-oil do not appear 
in the urine in organic diseases of the kidney. This, if true, 
might be valuable for diagnostic purposes, but more extended 
observation has not confirmed the assertion. 

Pathologically the odor of the urine renders some informa- 
tion. Thus, if the urine be ammoniacal when voided, it is strong 
evidence of the existence of cystitis. In suppurating conditions 
of the upper urinary tract the urine is often peculiarly offensive 
(putrid), m consequence of its contained decomposing pus, blood, 
and organic elements. In diabetes the urine often has the odor 
of acetone. Urine containing cystin possesses an odor, at first, 
like sweet briar, but subsequently becomes very offensive. 

Transparency. — The normal freshly-voided urine may be said 
to be always macroscopically clear ; after standing, a mucous 
cloud, more or less pronounced, usually appears, which is un- 
changed by alkalies, heat, or mineral acids. Pathologically the 
urine may become cloudy from various causes, as the precipita- 
tion of urates, carbonates, phosphates, or organic products, as 
blood, chyle, excess of mucus, pus, bacteria, etc. If the cloudi- 
ness of the urine disappear upon the application of gentle heat, 
it may be concluded that the turbidity was due to the presence 
of precipitated urates. If, on the contrary, the turbidity increase 
upon the application of heat, it is due either to precipitation of 
the earthy phosphates or to albuminous cell-elements, as pus or 
blood. If the phosphates be the cause of the cloudiness, the 
latter rapidly clears up by the addition of an acid. If, on the 
other hand, it become more turbid upon the addition of the acid, 
it may be concluded that pus, blood, or albuminous cell-elements 



12 ANALYSIS OF URINE. 

are the cause of the opacity. If the urine remain unchanged by 
the acetic acid, or if the turbidity be very slightly increased 
thereby, it may be concluded that mucus or micro-organisms are 
the cause of the turbidit}'. 

Consistence. — Normal urine is always of aqueous consist- 
ence ; that is to say, it drops and flows as does water. Patho- 
logically the urine may become thick and viscid, so that it flows 
from the vessel slowly and with difficulty, not separating into 
drops. Such is usually the case when the urine contains a large 
amount of mucus or pus, and especially if, in addition, the urine 
be alkaline. Diabetic urine, if heavily laden with sugar, is of 
diminished consistence, as is evidenced by its tendency to froth 
when agitated ; and the same ma}^ be said of highly-albuminous 
urine. In chylous urine, owing to the contained molecular fat, 
the fluid often becomes much thickened. In fibrinuria the urine, 
after standing, sometimes becomes thickened into a jelly-like con- 
sistence, so that it may stick to the vessel when the latter is 
inverted. 

Specific Gravity. — The average specific gravit}^ of normal 
urine of 1500 cubic centimetres (50 ounces) in volume for twenty- 
four hours is about 1020. Slight variations from this standard 
are consistent with perfect health, and depend chiefly upon the 
character of the food taken, as well as the quantity thereof, and 
the rapidity of tissue metamorphosis. If the diet consist largely 
of nitrogenous foods, they furnish a higher relative amount of 
solids than fluids to be excreted by the kidneys, and, conse- 
quently, the specific gravity of the urine will be somewhat in- 
creased. Upon active muscular exertion oxidation and tissue 
waste is hastened, which also tends to raise the specific gravity 
of the urine through furnishing a relatively large amount of 
solids to be excreted. Copious diaphoresis may bring about a 
concentrated condition of the urine, with an accompanying in- 
crease of specific gravity. The specific gravity of the urine may 
be lowered by fasting, or by imbibing large quantities of fluids. 
Very marked departures from the normal specific gravity of the 
urine often constitute pathological factors of great importance. 
In nearly all forms of organic albuminuria (Bright's disease) the 
tendency is toward a lowered specific gravity of the urine. 



PHYSICAL CHARACTERS OF THE URINE. 



13 



Acute diffuse nephritis and cyanotic induration of the kidney 
are exceptions to the foregoing rule ; in both these exceptions the 
increased specific gravity is due to marked diminution of the 
volume, — concentration. A lowered specific gravity of the urine, 
especially if the volume of the urine remain normal, should 
alwaj^s be regarded as suspicious of renal defect. An important 
fact to be noted in this connection is that, in most cases of so- 
called function a I albuminuria, the specific gravity of the urine is 
above the normal standard. Prognostically, in cases of nephritis, 
a reduction of the specific gravity of the urine without alteration 
of the volume thereof should always be regarded as of serious 
import. It usually indicates inability of the kidneys to excrete 
the normal amount of solids, and 
thus gives warning of approaching 
uraemia. If the specific gravity of 
the urine be markedly increased, it 
is strongly indicative of melituria. 
Should it reach as high as 1030, or 
above, search should always be made 
for sugar. 

To determine the specific gravity 
of the urine with accuracy the Mohr- 
Westphal balance, or pyknometer, 
is the most trustworthy instrument. 
A more simple instrument, better 
suited for general practical use, is 
one constructed on the principle of 

an hydrometer, termed the urinometer. If carefully constructed 
and properly corrected, such an instrument will answer all prac- 
tical purposes. Unfortunately, however, of all the simple instru- 
ments offered for sale the urinometer is the most useless in con- 
sequence of its faulty correction, it being not at all uncommon 
to find them at fault from 3 or 4 to 10 degrees. The urinometers 
made by E. R. Squibb are recommended as a notable exception 
to the above rule, as they meet all the requirements of the best 
instruments. These urinometers are standardized at 25° C. 
(11° F.),the ordinary temperature of dwelling-rooms, and there- 
fore temperature corrections are usually unnecessary in taking 




Fig. 1.— Squibb's Urinometer. 



14 ANALYSIS OF URINE. 

observations. The receiving-jar for the urine is fluted sharply in 
the middle, preventing the instrument from clinging to the sides ; 
and this is still further secured by the spindle-shaped form of the 
bulb of the instrument, so that a single point of contact is obtained 
between the instrument and the jar. Each instrument is care- 
fully tested, and any variation of the scale from the correct 
standard is marked on the case. 1 A thermometer is furnished, for 
the purpose of temperature corrections, with each instrument. 
In taking the specific gravity of the urine with the urinometer 
the glass-cylinder tube is filled about three-fourths full of the 
urine, and any froth appearing at the top is removed by filtering- 
paper or a pipette. The urinometer is next introduced into the 
urine and touched gently with the finger-tip, so that it sinks and 
rises a few seconds until it finds the correct level. When it 
comes to a rest the scale is read on a level with the eye, and the 
figure on a level with the surface of the urine is marked. 

The temperature of the urine immediately after being voided 
ranges from 85° to 95° F. (29.5° to 35° C.) ; therefore, in taking 
the specific gravity of freshly-voided urine, before cooling, its 
temperature should be observed, and for every 1 degrees of tem- 
perature the thermometer indicates above that upon which the 
urinometer is standardized 1 degree should be added to the 
specific gravity of the urine in addition to that indicated by the 
urinometer. This is important in the case of the older urinom- 
eters, many of which are standardized at 60° F. (15.6° C), per- 
mitting, as will be seen, an error of 4 or 5 degrees with freshl}- 
voicled urine if the above correction be neglected. 

Chemical Reaction. — Normal mixed urine — that is to say, the 
whole twenty -four hours' product — is always acid. The acidity 
is due to acid sodium phosphate, and not, as formerl} T supposed, 
to free acid. This sodium phosphate is derived from the basic 
sodium phosphate of the blood ; the uric, hippuric, sulphuric, 
and carbonic acids of the urine take up part of the sodium, leaving 
an acid salt. 

The degree of acidity of the urine varies at different times of 
the day, especially with regard to food. Soon after a meal the 

1 These instruments are furnished by Eimer & Amend, 205 and 211 Third 
Avenue, New York. 



PHYSICAL CHARACTERS OF THE URINE. 15 

acidity begins to diminish, and in from three to four hours the 
alkaline tide usually reaches its height ; occasionally, though 
rarely, the acidity may become so diminished at such times that 
the urine gives an alkaline reaction with test-paper. Freshly- 
voided urine may be alkaline either from fixed alkali (potassium 
or sodium) or from volatile alkali (ammonia). It is important 
to distinguish between these two conditions, as in the first case 
it merely reflects a condition of the blood, while in the second 
case it is nearly always associated with chronic inflammatory 
conditions of the lower urinary tract, notably the bladder. If 
red or violet litmus-paper turn blue in contact with urine just 
voided, and remain blue upon drying, the reaction is due to fixed 
alkali. If, on the other hand, the paper return to the original color 
upon drying, the reaction is due to volatile alkali (ammonia). 

The urine is rendered alkaline by the administration of alka- 
line carbonates or the salts of vegetable acids. The urine may 
be rendered alkaline, usually to a less extent, by the following 
circumstances : Soon after a full meal ; after the discharge of 
gastric juice in abnormal ways, — through fistula or by copious 
vomiting ; after hot baths and free perspiration ; upon a vegetable 
diet. With vegetarians, as with herbivorous animals, the food 
contains an excess of alkaline salts or vegetable acids. These 
acids are converted into carbonates in the blood, which, passing 
into the urine, cause an alkaline reaction. 

The acidity of urine is increased by the ingestion of acids, 
saccharin, a purely meat diet, and prolonged muscular exercise. 
It may be developed, as already shown, by acid fermentation, 
and in certain pathological conditions free fatty acids may ap- 
pear and render the urine sharply acid (lipaciduria). 

Occasionally it happens that the urine is amphoteric, — i.e., 
the same urine turns red litmus-paper blue and blue litmus red. 
This seemingly paradoxical reaction, according to Huppert, 
depends upon the presence of acid and neutral phosphates in 
variable proportions. 

Quantity. — The average quantity of urine of a health}' indi- 
vidual who eats and drinks in moderation, and lives in a temper- 
ate atmosphere, is about 1500 cubic centimetres (50 ounces) in 
twenty-four hours. The relative quantity varies considerabl} r 



16 ANALYSIS OF URINE. 

with the time of day, most being passed in the afternoon, less 
in the morning, and least at night. The volume of urine for 
twenty-four hours varies much in conditions of health, according 
to certain circumstances. It is decreased by unusual activity 
of the skin and bowels, as well as by rest and abstaining from 
fluids. It is decidedly increased b}^ imbibing large quantities of 
fluids, the use of diuretic drugs, to a less extent by cold, atmos- 
pheric moisture, exercise, and liberal eating. 

Pathologically the urine is increased in diabetes, cirrhosis of 
the kidney, amyloid or waxy kidney, pure cardiac hypertrophy, 
P3 r elitis, hysteria, and convulsions. The quantity of urine is 
decreased in acute nephritis, cyanotic induration from cardiac 
defect, acute fevers, and inflammations. The urine may be more 
or less completely suppressed in the acute forms of nephritis, in 
the algid stage of cholera and yellow fever, by violent fevers and 
inflammations, by shock or collapse from internal injuries, — as 
rupture of the liver, spleen, bowels, or other viscera, — by the 
reflex shock or the congestion following catheterization (urinary 
fever), and by obstructive diseases of the urinary passages, no- 
tably the ureters. Finally, it is important to observe that in 
nephritis more or less complete suppression of the urine, often 
followed by uraemia and death, may result from the administration 
of anaesthetics such as chloroform and ether, notably the latter. 

In estimating the quantity of urine it should be carefully 
collected for twenty-four hours, in an accurately-covered vessel, 
in order to exclude dust and prevent evaporation, the patient 
being directed to void and collect the urine previous to each 
movement of the bowels. 

Solids. — In determining the solids of the urine observations 
should be made upon a sample of the mixed product of the kid- 
neys for the whole twenty-four hours. The most accurate results 
are obtained by taking a given quantity of urine, — say, 20 cubic 
centimetres, — in a previously-weighed porcelain dish, and evapo- 
rating it over a water-bath. It should then be dried in a warm 
chamber for an hour or so, and then allowed to cool, when it 
should be weighed. This should be repeated a number of times 
until there is no further loss of weight from drying ; then the 
difference in weight between the empty dish and that containing 



PHYSICAL CHARACTERS OF THE URINE. 



17 



the dried solids constitutes the weight of the solids in 20 cubic 
centimetres of the urine. From this the solids of the whole 
volume of urine may be readily reckoned. 

The foregoing method being somewhat tedious, and, besides, 
consuming too much time for practical work, approximate results 
may be more readily obtained by multiplying the last two figures 
of the specific gravity of the urine by the co-efficient of Haser, 
which is 2.33. This gives, approximately, the number of grammes 
of solids in each 1000 cubic centimetres of the urine. 

Example. — If the twenty-four hours' urine be 1500 cubic 
centimetres, and the specific gravity be 1.020 with Haser 's co- 
efficient, then we have as follows : — 
20 X 2.33 = 46.60 grammes in 1000 cubic centimetres of urine; 

^ _ 46.60 X 1500 aQQ _ ' ■ 

therefore, — = 69.9 grammes of solids. 

1000 & 

Table for Estimating Total Solids from Specific Gravity. 



Specific Gravity. 


Solids Found by Weighing. 


Solids Found by Multi- 
flying by 0.233. 




Per Thousand: 


Per Thousand: 


1.0160 


37.4 


37.28 


1.0260 


62.0 


60.58 


1.0154 


35.1 


35.88 


1.0261 


60.2 


60.81 


1.0213 


48.6 


49.63 


1.0230 


56.4 


53.59 


1.0225 


49.3 


52.42 


1.0240 


54.1 


55.92 


1.0257 


60.4 


59.88 


1.0275 


63.9 


64.07 


1.0217 


48.5 


50.56 


1.0223 


52.15 


51.96 


1.0140 


31.08 


32.62 


1.0236 


56.64 


54.98 


1.0133 


30.87 


30.99 


1.0134 


31.06 


31.22 


1.0238 


57.09 


55.45 


1.0250 


60.47 


58.25 


1.0164 


37.26 


38.21 


1.0135 


33.35 


31.45 


1.0210 


48.54 


48.93 


1.0137 


32.55 


31.92 


1.0085 


19.16 


19.80 


1.0110 


24.96 


25.63 




Average : 




. 1.0200 


46.59 


46.52 



18 ANALYSIS OF URINE. 

From these determinations it will be found that, by dividing 
the mean quantity of solid constituents found in 1000 grammes 
of urine by the last three decimals of the mean specific gravity, 
we obtain the quotient 0.23295, for which we may conveniently 
substitute the number 0.233, as Haser suggests. By multiplying 
with this quotient the three last decimals of the specific gravity 
carried out to four places of decimals, we obtain the figures in 
the third column of the table. The variations from the results 
obtained by actual weighing may be seen by a glance at the 
table. If, however, as is usual, the specific gravity of the urine 
be determined only to three decimals, the second and third fig- 
ures multiplied by 2.33, as suggested by Haser, give approxi- 
mately the amount of solid matters in 1000 parts of urine. 

A material reduction of the solids of the urine in cases of 
renal disease indicates a tendency to uraemia, and therefore puts 
the physician on his guard against this dangerous complication. 
The diagnosis between diabetes insipidus and hydruria may be 
determined by the amount of solids in the urine. The so-called 
renal inadequacy — an unscientific term introduced by Sir An- 
drew Clark, which usually means unrecognized interstitial ne- 
phritis — and the anazoturia of Willis are both indicated by a 
reduction of the solids of the urine. 

During the course of acute fevers and inflammations the 
quantity of solids in the urine furnishes very valuable information 
as a guide both for prognosis and treatment. The amount of 
tissue metamorphosis, as evidenced by the quantity of solids 
in the urine, is a good indication of the severity of the disease. 
If these changes be too active, measures are indicated for re- 
straining them. If exudations are to be removed, a copious ex- 
cretion may indicate to us that the chemico-vital changes ending 
in elimination are progressing sufficiently without artificial aid. 
Again, by insufficiency of the urinary solids defective elimination 
may be detected when the thermometer indicates a high ratio of 
tissue metamorphosis in progress, and we are thereby admon- 
ished to employ measures to re-establish elimination. 

No definite deductions are to be drawn, from the quantity of 
solids present, as to the relative amount of any special product, 
especially that of urea. Since the amount of urea normally con- 



PHYSICAL CHARACTERS OF THE URINE. 19 

stitutes about one-half of the solids excreted by the kidneys, it 
has been suggested that an approximate knowledge of the amount 
of urea is to be gained by merely dividing the whole quantity of 
solids by 2. Such a rule should never be suggested as a guide 
in pathological conditions, because, under such circumstances, 
the various solids of the urine are often present in widely dif- 
ferent proportions, as well as quantities. In addition to this, 
the special solid constituents of the urine possess widely different 
specific gravity, — notably that of urea from sodium chloride, 
which is as 2 to 3. For these reasons, even when the total solids 
are determined with accuracy, the amount of urea, nitrogen, or 
other constituent, if sought, can only be determined by special 
quantitative methods, which will be described in the succeeding 
section of this work. 

Having ascertained the actual quantity of solids in the urine, 
in order to make deductions therefrom of any definite value in 
health or disease, careful regard must be had to certain con- 
ditions and features connected with each individual case before 
we can determine the degree in which the quantity of solids is 
excreted above or below the average or normal standard for 
such individual case. Those that chiefly influence the normal 
balance of excretion can be reduced to a ratio that will afford 
approximate results of definite and practical value. The most 
prominent of these conditions are : the weight of the individual, 
the age, the diet, and the amount of exercise taken. We may 
place the average weight at 66 kilogrammes (145 pounds) avoir- 
dupois, the age being from 20 to 40, the diet that of ordinary 
mixed foods, and the exercise being that of the usual healtlry 
man about ordinary labor. To the above standard the following 
general rules may be applied : — 

1. The average excretion of solids per weight of 145 pounds 
being 61.14 grammes (945 grains), a proportional reduction or 
addition should be allowed, according to the weight of the sub- 
ject examined. 

2. Deduct 10 per cent, from the average solids in persons be- 
tween 40 and 50 years of age, 20 per cent, if between 50 and 60, 
30 per cent, if between 60 and 10, and 50 per cent, above 70. 

3. For Diet. — In persons who have fasted for two or more 



20 ANALYSIS OF URINE. 

days, as in some fevers and other diseases, deduct one-third from 
the average solids. If the diet be spare, deduct one-eighth to 
one-sixth ; if rather plentiful, but still below that of health, de- 
duct one-tenth. 

4. For Exercise. — If there be total rest, deduct one-tenth 
from the average solids ; but if merely quietude, deduct one- 
twentieth. 

The average standard of excretioii of solids by the kidneys 
(61.14 grammes — 945 grains — for weight of 66 kilogrammes — 
145 pounds avoirdupois) represents the mean of the combined 
observations by Becquerel, Parkes, Bocker, J. Yogel, Lehman, 
Gorup Besanez, Ranke, and Hummel, obtained by evaporating 
the urine and determining the solids by actual weighing. The 
rules for correction are based on the proportions laid down by 
Parkes. 



SECTION II. 

COMPOSITION OF NORMAL URINE. 
ORGANIC CONSTITUENTS. 

Urea— CO(NH 2 ) 2 . 
Urea, or carbamide, was first prepared synthetically from 
ammonium cyanate — (NH 4 )CNO — by Wohler (1828). From 
the urine it was first prepared in an impure state by Rouelle, 
and subsequently by Fourcroy and Yanquelin. Urea crystallizes 
in colorless, quadrilateral, or six-sided, silk-like prisms with 
oblique ends, or, when rapidly crystallized, in delicate white 




Fig. 2.— Crystals of Urea. 

needles, which melt at 120° C. (248° P.). They contain no water 
of crystallization, and are permanent in the air, soluble in cold 
water, the solution being neutral in reaction. With nitric acid 
urea unites to form nitrate of urea (CON 2 H 4 HN0 3 ), which 
crystallizes out in octahedral, lozenge-shaped, or hexagonal 
plates, which are less soluble in water than are urea crystals. 

Urea owes its origin in the economy partly to retrograde 
tissue metamorphosis, including the blood, and partly to splitting 

(21) 



22 ANALYSIS OF URINE. 

up of unassimilated nitrogenous principles of the food. Thus, the 
greater portion of nitrogen taken into the system in the way of 
food is excreted by the kidneys in the form of urea. It is there- 
fore the most bulky single constituent of the urine, ranging in 
quantity, according to circumstances, from 20 to 40 grammes 
(300 to 600 grains) in twenty -four hours in the healthy adult. 

That the liver constitutes the chief seat of urea formation is 
now pretty generally accepted as fact. This was originally 
claimed to be the case by Meissner, and more recently confirmed 
by Brouardel, Schroeder, and Minkowski. It is not improbable, 
however, that the spleen and perhaps the lymphatic and secreting 
glands to some extent participate in the urea formation. For- 
merly it was erroneously supposed that urea was formed in the 
kidneys ; but it is now known that after complete extirpation of 
the kidneys the formation of urea continues as before, and accu- 
mulates in the blood. Likewise, in diseases of the kidney entail- 
ing suppression of the urine, urea continues to be formed and 
accumulates in the organism. The evidence derived from pathol- 
ogy strongly points to the liver as the chief seat of urea forma- 
tion. Thus, in diabetes, we know that metabolism of the hepatic 
cells is greatly increased, causing an abundant formation of sugar 
as well as urea, which pass into the blood and are excreted by the 
kidneys. On the other hand, in degenerative changes in the liver 
the urea formation is markedly diminished. Thus, in acute 
yellow atrophy of the liver the urea in the urine is greatly dimin- 
ished — sometimes absent. The relations of degenerative changes 
in the liver to urea formation have recently been much elucidated 
by Noel Paton, 1 who points out that two functions of the liver 
exist — bile formation and urea formation — and, moreover, that 
they bear a direct relationship to each other. It has already 
been stated that urea owes its origin in the economy to retrograde 
tissue metamorphosis and nitrogenous principles of the food ; in 
other words, the proteid constituents in the organism. Of the 
intermediate steps in this transformation but little is definitely 
known, although much has been written on this subject, most of 
which is conjectural. The excretion of urea reaches its maximum 

1 British Medical Journal, vol. ii, 1886, p. 207. 



NORMAL CONSTITUENTS OF URINE. 23 

quantity upon an exclusive meat diet ; much less is excreted upon 
a mixed diet, and least of all upon a strictly vegetable diet. 

Variations in the quantity of urea excreted, in a measure, 
constitute an expression of the changes in nitrogenous tissue 
metabolism, and as such possess definite clinical value. Thus, in 
acute fevers and inflammations, until the crisis of the disease is 
reached there is greatly increased elimination of urea. On the 
other hand, in chronic diseases (cachexias), when tissue meta- 
morphosis is retarded through malnutrition, the excretion of urea 
is diminished. Similar results follow in diseases involving the 
integrity of the liver, — the elaborating source of urea. In 
Bright's disease urea excretion is diminished in consequence of 
impairment of the structure of the kidneys. Preceding, usually 
for some time and during uremic attacks, the excretion of urea is 
markedly diminished, forming a valuable indication of the ap- 
proach of this dangerous complication. Mental and muscular 
activity hasten urea excretion by accelerating tissue waste ; and 
hence urea excretion is more active during waking than during 
sleeping hours. The variations in the amount of exercise, the 
quantity and quality of food taken, atmospheric vicissitudes, the 
degree of activity of the other excretory organs, etc., render the 
relative and absolute amount of urea excreted almost as variable 
as the amount of water. If the mode of life be very regular and 
equable, the amount remains pretty uniform ; but great care is 
necessary to maintain all the physiological conditions even. 
Under the latter circumstances the mean amount of urea ex- 
creted in twenty-four hours, by healthy adult males between 
the ages of 20 and 40 years, is 33.18 grammes (512.4 grains). 
Close calculations give the average excretion of urea as .015 to 
.035 gramme per hour for each kilogramme of body -weight. The 
absolute quantity of urea excreted by women is below the average 
of men. The same is true with children ; but, on the other hand, 
the relative quantity excreted by children is much higher than 
by either men or women. 

Urea may be separated from the urine as follows : First 
evaporate, then add strong, pure nitric acid in excess, keeping 
the mixture cool during acidulation. Pour off the excess of fluid 
from the crystals of urea nitrate formed ; strain through muslin 



24 ANALYSIS OF URINE. 

and press between heavy filter-paper. Add to the dry product 
barium carbonate in excess, and add sufficient alcohol to form a 
pasty consistence. Dry on a water-bath, and extract with al- 
cohol ; filter ; evaporate the filtrate on a water-bath, and set aside 
to crystallize. The result is nearly pure urea, plus the coloring 
matters of the urine. The simplest method of decolorizing the 
product is to filter through animal charcoal, and afterward purify 
by recrystallization. 

Detection. — 1. A very simple method of detecting urea is to 
place a drop or two of the suspected fluid upon a glass slide, and 
after adding a drop of nitric acid gently warm over a spirit-lamp. 
If urea be present, upon evaporation the microscope will show 
the characteristic crystals of nitrate of urea, of rhombic or hex- 
agonal forms, singly or in masses, their acute angles being eighty- 
two degrees. 

2. Add to the suspected fluid three parts of an aqueous solu- 
tion of furfur aldehyde, and subsequently a few drops of strong 
hydrochloric acid, and warm. A series of colors — } T ellow, green, 
violet, purple, and red — is produced, settling at length into a 
brown, sticky mass if urea be present. 

3. To a few drops of the suspected fluid in a test-tube add 
an equal quantity of solution of hypobromite of sodium, and a 
rapid evolution of bubbles takes place if urea be present. 

4. Warm a few crystals of urea in a test-tube ; add a trace of 
sodium or potassium lrvdrate and a drop of a dilute solution of 
cupric sulphate. A violet or rose-red color is produced, — the 
biuret reaction. 

Determination of Urea. — The methods devised for the purpose 
of determining the quantity of urea in the urine are very numer- 
ous ; most of which, however, are founded upon one of three 
principles : 1. The mercuric nitrate, or Liebig's method. 2. The 
hypobromite, or Knop-Hufner method. 3. The differential den- 
sity method, obtained by measuring the amount of urea by the 
specific gravit}^ of the urine lost through decomposition of the 
contained urea. 

Liebig's Method. — The combination between urea and mer- 
curic oxide— (CON 2 H 4 ) 2 Hg (N0 3 ) 2 -f 3 HgO— forms a white 
precipitate, insoluble in water and weak alkaline solutions. It 



NORMAL CONSTITUENTS OF URINE. 25 

is, therefore, necessary to prepare a standard solution of mercury, 
and to have an indicator by which to detect the point when all 
the urea has entered into combination with the mercury, the latter 
slightly predominating. This indicator is sodium carbonate, 
which gives a yellow color with the excess of mercury, in conse- 
quence of the formation of hydrated mercuric oxide. 

Theoretically, 100 parts of urea should require 720 parts of 
mercuric oxide ; but practically -7 72 parts of the latter are neces- 
sary to remove all the urea, and at the same time to show the 
yellow color with alkali; therefore, the solution of mercuric 
nitrate must be of empirical strength in order to give accurate 
results. The following solutions are required for testing : — 

1. Standard mercuric nitrate solution. Dissolve 77. 2 grammes 
(1158 grains) of red oxide of mercury (weighed after drying over 
a water-bath), or 71.5 grammes (1072 grains) of the metal itself 
in dilute nitric acid. Expel the excess of acid by evaporation to 
a syrupy consistence. Make up to 1000 cubic centimetres with 
distilled water, adding the water gradually. This solution is 
of such strength that 19 cubic centimetres will precipitate 10 
cubic centimetres of a 2-per-cent. urea solution. Add 52.6 cubic 
centimetres of water to the litre of the mercuric nitrate solution, 
and shake well; then 20 cubic centimetres (instead of 19) equal 
10 cubic centimetres 2-per-cent. urea solution, — i.e., 1 cubic centi- 
metre equals 0.01 urea. 

2. Baryta mixture. Prepare by mixing two volumes of 
solution of barium hydrate with one volume of solution of barium 
nitrate, both saturated in the cold. 

Analysis. — Take 40 cubic centimetres of urine, add to this 
20 cubic centimetres baryta mixture and filter off the precipitate 
of baryta salts (phosphates and sulphates). Take 15 cubic centi- 
metres of the filtrate (corresponding to 10 cubic centimetres of 
urine) in a beaker. Discharge into it the mercuric nitrate solu- 
tion from a burette, until, on mixing a drop of the mixture with 
a drop of saturated solution of sodium carbonate on a white tile, 
a pale-lemon color appears. Then read the amount used from the 
burette, and calculate thence the percentage of urea. 

Corrections. — This method only approaches accuracy when 
the quantity of urea present is about 2 per cent., — the normal 



26 ANALYSIS OF URINE. 

percentage of urea in the urine. The chlorine in the urine 
must be estimated, and the quantity of urea indicated reduced 
by subtraction of 1 gramme (15 grains) of urea for every 1.3 
grammes (19 grains) of sodium chloride found. If the urine 
contain less than 2 per cent, of urea, 0.1 cubic centimetre of mer- 
curic nitrate solution must be deducted for every 4 cubic centi- 
metres used ; if more than 2 per cent, of urea, a second titration 
must be performed, with the urine diluted with half as much 
water as has been needed of the mercurial solution above 20 cubic 
centimetres. Suppose, then, 28 cubic centimetres have been used 
in the first titration, the excess is 8 cubic centimetres ; therefore, 
4 cubic centimetres of water must be added to the urine before 
the second titration is made. When ammonium carbonate is 
present, first estimate the urea in one portion of urine, and the 
ammonia by titration with normal sulphuric acid in another; 
0.017 gramme of ammonia equals 0.030 gramme of urea. The 
equivalent of ammonia in terms of urea must be added to the 
urea found in the first portion of the urine. 

Modifications. — Rautenberg 1 and Pfliiger 2 have devised the 
following modifications of Liebig's original method, just de- 
scribed : — 

Rautenberg 's method consists in maintaining the urea solu- 
tion neutral throughout by successive additions of calcium 
carbonate. 

Pjiuger's modification is the one most generally employed, 
which is as follows : A 2-per-cent. solution of urea is prepared ; 
10 cubic centimetres of this are placed in a beaker, and 20 cubic 
centimetres of the mercuric nitrate solution are run into it in a 
continuous stream ; the mixture is then placed under a burette 
containing normal sodium carbonate, and this is added, with 
constant agitation, until a permanent yellow color appears. The 
volume so used is noted as that necessary to neutralize the acidity 
produced by 20 cubic centimetres of the mercurial solution in 
the presence of urea. A plate of glass is then laid on black 
cloth, and some drops of a thick mixture of sodium bicarbonate 

1 Ann. Chem. Pharm., vol. cxxxiii, p. 55. 

2 Zeit. anal. Chem., vol. xix, p. 375. Pfeitfer (Zeit. Biol., vol. xx, p. 540) 
has carefully compared the different methods. 



NORMAL CONSTITUENTS OF URINE. 27 

(free from carbonate) and water placed upon it at convenient 
distances. The mercurial solution is added to the urine in such 
volume as is judged appropriate, and from time to time a drop 
of the white mixture is placed beside the bicarbonate, so as to 
touch but not mix completely. A point is at last reached when 
the white gives place to yellow ; both drops are then rubbed 
quickly together with a glass rod, and the color disappears ; fur- 
ther addition of the mercury is then made to the urine till a 
drop rubbed with the bicarbonate remains permanently yellow. 
Now neutralize by the addition of the normal sodium carbonate 
to near the volume found necessary in the preliminary experi- 
ment. If this be quickly done, a few tenths of a cubic centi- 
metre of mercuric nitrate will be found sufficient to complete 
the reaction. If much time has been lost, however, it may 
occur that, notwithstanding the mixture is distinctly acid, it 
gives, even after the addition of sodium carbonate, a permanent 
yellow, although no more mercuric nitrate be added. The 
analysis, under such circumstances, must be repeated, taking 
the first titration as a guide to the quantities which are neces- 
sary. Pfliiger's correction for concentration of urea is different 
from Liebig's, and is as follows : — 

Y 1 = volume of urea solution -J- volume of sodium-carbonate 
solution + volume of any other fluid free from urea which 
may be added. 

Y 2 == volume of mercuric nitrate solution used. 

C = correction ==— (Y 1 — Y 2 ) X 0.08. 

This formula holds good for cases in which the total mixture 
is less than three times the volume of mercuric nitrate solution 
used ; with more concentrated solutions the formula gives 
results too high. 

Hypobromite Method. — This is a far more simple and ready 
method to manipulate. The principle of the method introduced 
by Knop depends upon the fact that, when urea in solution 
comes in contact with sodium-hypobromite solution, nitrogen is 
set free as a result of the total decomposition of the urea. 
Thus :— 

CH 4 ON 2 + 3NaBrO = CO a + 2H a O + 3NaBr + 2N. 



28 



ANALYSIS OF URINE. 




The C0 2 is absorbed by the sodium-hj'droxid solution. One 
gramme of urea furnishes 370 cubic centimetres of nitrogen at 
0° C and under 760 millimetres pressure. Knop's lrypobromite- 
of-sodium fluid is made as follows : In 250 cubic 
centimetres of distilled water 100 grammes of 
sodium hydrate are dissolved, and after cool- 
ing 25 cubic centimetres of bromine are added. 
A number of apparatuses have been devised 
for carrying out this method, the best known 
of which are those of Hufner, Dupre\ and 
Gerrard. But altogether the simplest and 
most ready method of carrying out the hypo- 
bromite test is by means of the instrument 
devised by Doremus, of New York, which 
gives very satisfactory approximate results 
for rapid clinical work. 1 The bulb of the 
instrument is filled with the alkaline hypo- 
bromite solution, and by inclining 
the tube the long arm is filled to the 
bend at the bulb. 2 By means of the 
nipple-pipette, 1 cubic centimetre of 
the urine to be tested is slowly dis- 
charged up the long arm into the 
Irvpobroniite solution. A rapid de- 
composition of urea takes place ; 
the bubbles of nitrogen rise in the 
long arm of the instrument, while 
the displaced liquid flows into the 
bulb, which serves as a reservoir for 
In fifteen minutes the decomposition of urea is 



— 0-02 
k 



— eo3 




Fig. 



3.— Dr. Doremus's 
Ureometer. 



the overflow. 



1 Messrs. Eimer & Amend, 205 and 211 Third Avenue, New York, supply 
these instruments at very moderate cost. 

2 As the hypohromite solution does not keep well, it is hest to keep the 
hromine and the sodium-hydrate solution separate, as follows: Have on hand a 
solution of sodium hydroxid, 100 grammes to 250 cubic centimetres of water 
(6 ounces to the pint). In another bottle should be kept the bromine. To pre- 
pare the solution freshly for use, take 10 cubic centimetres of the sodium- 
hydroxid solution, and add thereto 1 cubic centimetre of bromine (1 to 10). 
After the bromine has been thoroughly mixed with the alkali, dilute with an 
equal volume of water, and the solution is ready for testing. 



NORMAL CONSTITUENTS OF URINE. 29 

complete, and the graduation on the long arm will indicate the 
quantity of urea in the volume of urine tested. Two forms of 
the instrument are furnished, — one graduated to read fractions 
of a gramme to the cubic centimetre of urine, and the range is 
from 0.01 to 0.03 gramme. If it be desired to read the per- 
centage of urea instead of the grammes per cubic centimetre, 
simply remove the decimal-point two figures to the right, — thus, 
0.02 gramme to the cubic centimetre is 2.0 per cent, of urea. 
The other form of the instrument is similar, save that it is 
graduated to show the number of grains of urea per fluidounce 
of urine. 

The normal quantity of urea in the urine is about 2 per 
cent., or 0.02 gramme per cubic centimetre, or 10 grains per 
ounce. 

The differential density method, as devised by Dr. George B. 
Fowler, of New York, is very simple in application. This 
method is based upon the fact that there is a difference in the 
specific gravity of urine before and after the decomposition of 
its urea by the hypochlorites. Every degree of density lost 
corresponds to 0.77 per cent., or about 3^ grains per ounce. 
The hypochlorite solution employed is Squibb's solution of 
chlorinated sodium (Labarraque's solution), of which seven parts 
will destroy the urea in one part of urine, unless the amount is 
very large, in which case the urine should be diluted with an 
equal bulk of water and the result multiplied by 2. The process 
consists in adding to one volume of urine — say, one ounce in a 
large hydrometer jar— seven volumes of Labarraque's solution. 
Decomposition immediately ensues, and at the expiration of a 
few hours all the nitrogen of the contained urea has escaped. 
The specific gravity of the quiescent mixture is now noted, and 
also that of the pure urine. We now have the specific gravity 
of the mixture of the urine and Labarraque's solution after 
decomposition. In order to ascertain what it was before decom- 
position, we resort to the law of proportions. Multiply, there- 
fore, the specific gravity of the Labarraque solution b} r 7, add 
the specific gravity of the urine, and divide the sum b} r 8. Now, 
from this — the specific gravity of the mixture before decompo- 
sition — subtract that obtained after decomposition. Multiply the 



30 ANALYSIS OF URINE. 

difference in degrees by 3^, and the result will be the number of 
grains of urea per ounce of urine; or, better, by 0.77, which 
gives the percentage of urea. The presence of sugar or albumin 
in the urine does not interfere with this test. 

Uric Acid (C 5 H 4 N 4 3 ). 

Uric acid, like urea, is a nitrogenous product, although it 
exists in the urine in comparatively small amount, — about 0.4 to 
0.8 gramme being excreted b}^ the kidneys in the healthy man in 
twenty-four hours. Upon decomposition uric acid yields about 
33.3 per cent, of its weight in nitrogen. It is feebly soluble, 
requiring 15,000 parts of cold or 1900 parts of boiling water 
to dissolve it. It is, for the above reason, rarely found in the 
urine in the free state; more often in the form of crystalline 
deposit, — reddish sand ; most often, however, it exists in combi- 
nation as urates. 

Uric acid is dibasic ; that is to say, it contains two atoms of 
H which may be substituted by two atoms of a monad metal. 
Urates containing but one atom of potassium, sodium, or ammo- 
nium are acid urates ; those containing two atoms are neutral 
salts. The neutral salts of uric acid are readily soluble in 
water, while the acid salts are but feebly so. The above fact 
explains the reason why nearly all urate deposits consist of acid 
urate salts ; their feeble solubility permits them to fall out of 
solution as the urine cools. If the urine remain clear for some 
time after cooling, we may infer that the contained urates are in 
the soluble form of neutral urate, the alkaline base predominating. 
When a strong acid is added to such a urine, — especially if the 
urates be present in excess, — the acid unites with the excessive 
base and forms an acid urate, which, on account of its relatively 
feeble solubility, is at once precipitated in finely-granular form, 
producing a whitish opacitj^. This explains the occasional error 
of the nitric-acid test for albumin when the urine is highly 
charged with neutral urates. 

Uric acid c^stallizes in the urine in rhombic, rectangular 
prisms, wedge- and whetstone- shape, of yellowish-red color, con- 
stituting, with its salts, the only sediments of the urine thus 
colored. 



PLATE III 




Uric- Acid Crystals. Normal Color. (After Peyer.) 



NORMAL CONSTITUENTS OF URINE. 



31 



Uric acid corresponds with urea in its protein origin in the 
organism, but the seat of its formation has given rise to much 
discussion. Two different views are held upon this subject : 1. 
That, like urea, it is formed in the tissues, notably in the spleen 
and liver, and merely excreted by the kidneys. This view is 
supported by the following facts : (a) In the normal condition 
but a small amount of uric acid is found in the blood, (b) In 
gout, where excretion of the uric acid is diminished, it areumu- 
lates in the blood and tissues. 
(c) After extirpation of the 
kiclne3 T s it continues to be 
formed, (d) The secretion of 
uric acid is most abundant at 
the period of digestion, when 
the liver and spleen are the 
most active. 2. This view sup- 
poses that the kidneys not only 
constitute the seat of excretion, 
but also that of formation of 
uric acid. Gar rod has ably 
supported this view, 1 basing 
his conclusions, first, on the 
fact of the small amount of uric acid in the blood of birds 
and reptiles, and also that he was unable to find more uric 
acid in the liver and spleen of birds than in those organs 
in mammals. But Schroeder has recently shown (1) that 
the liver of birds contains a high percentage of uric acid ; 
(2) that after removal of the kidneys uric acid continues to 
be formed, and accumulates in the blood and liver; (3) that 
by passing blood through the liver, immediately after removal 
of that organ from the bodj r , it is found that the uric acid is 
much increased ; and (4) he regards ammonia as the most im- 
portant precursor of uric acid, just as in mammals it is the most 
important precursor of urea. 2 In addition to this, the experi- 
ments of Minkowski are still more conclusive. He succeeded in 
keeping geese alive for from six to twenty hours after extirpation 

1 Luraleian Lectures, Lancet, vol. i, 1SS3. 

2 Ludwig's Festschrift, 1887, p. S9. 




Fig. 4.— Uric-Acid Crystals. 
(Alter Kuhn.) 



32 ANALYSIS OF URINE. 

of the liver ; after the operation their urine contained but 2 or 
3 per cent, of uric acid, instead of the normal 60 or 70 per cent. ; 
the ammonia was corresponding^ increased to 50 or 60 per- 
cent., instead of the normal 9 to 18 per cent. 

All the facts at present available render the following con- 
clusions probable: 1. That uric acid is formed chiefly in the 
liver. 2. It is formed by the synthesis of ammonia and lactic 
acid, which, after the removal of the liver, appear in the urine 
in equivalent quantities. 3. That the remnant of uric acid in the 
urine after extirpation of the liver originates from xanthin and 
similar products. 

The quantity of uric acid in the urine should never be pre- 
sumed to be excessive from the mere fact of deposit of uric-acid 
crystals in the urine upon cooling, as in fact such may, and very 
often does, occur when the uric acid is both relatively and abso- 
lutely deficient. The conditions of the urine which tend to pre- 
cipitation of uric acid are as follow : 1. High grade of acidity 
of the urine. 2. Poverty in mineral salts. 3. Low percentage 
of pigmentation. 4. High percentage of uric acid. 5. Long 
standing. An}^ urine upon standing sufficientl}^ long will deposit 
uric-acid crystals in consequence of the changes culminating in 
ammoniacal decomposition. 

As already stated, the quantity of uric acid excreted in twenty- 
four hours by the average healthy man ranges from 0.4 to 0.8 
gramme (6 to 12 grains). The proportion of urea to uric acid 
is stated by Parkes to be about 45 to 1. 

Uric-acid excretion is increased by a rich animal diet, es- 
pecially if combined with limited exercise in the open air ; by 
acute febrile conditions; by lung and heart diseases, attended by 
dyspnoea ; bj^ diseases which impede respiration, as large ab- 
dominal tumors, ascites, etc. ; b} T leukaemia ; and by the so- 
called uric-acid cachexy. Uric acid, on the other hand, is 
diminished in advanced Bright's disease, urina spastica, hy- 
druria, arthritis (especially the gouty form), gout, and, in 
general, wherever urea is diminished in quantity uric acid is 
usually also diminished. 

Detection of Uric Acid. — 1. Uric acid, as such, is easily recog- 
nized by the microscope, owing to the characteristic rhombic, 



NORMAL CONSTITUENTS OF URINE. 33 

yellowish-red crystals. The microscope also most readily dis- 
tinguishes uric acid from its compounds. 

2. The presence of both uric acid and its compounds may be 
readily detected b} r means of the murexide test. The sediment, 
or residue, after evaporation, is first treated with a few drops 
of nitric acid in a porcelain capsule, and, after warming over a 
spirit-lamp until evaporated almost to dryness, a drop or two of 
ammonia is added, and, if present, a beautiful purple-red color 
immediate^ appears, gradually diffusing over the bottom of the 
capsule. 

The murexide test depends upon the facts that, by the ad- 
dition of nitric acid and heat to uric acid or urates, first alloxan 
and subsequently alloxantin are formed, which, on the addition 
of ammonia, form murexide, — acid purpurate of ammonium. 

3. If one or two drops of nitrate-of-silver solution be dropped 
upon white filter-paper, and then touched with an alkaline solu- 
tion of uric acid (sol. with sodium carbonate), a black color ap- 
pears if 0.001 per cent, of uric acid be present ; even 0.0005 per 
cent, of uric acid, if present, will cause a brownish-yellow or 
grayish stain. 

4. A solution of uric acid or urate, warmed with copper sul- 
phate and caustic potash, produces a reddish precipitate of 
cuprous oxide. 

Determination of Uric Acid. — An approximate and sufficiently 
accurate process for most clinical purposes is Heintz's method, 
which is also very simple : Take 200 cubic centimetres of urine, 
and add to it 10 cubic centimetres of hydrochloric acid. Let 
stand for twenty-four hours in a cool room. Collect the precipi- 
tated uric-acid crystals on a previously-weighed filter, and wash 
with cold distilled water. Dry the filter and uric-acid crystals 
in a desiccator, and weigh. By subtracting the weight of the 
filter, the result will be the weight of the uric acid in 200 cubic 
centimetres of urine. If albumin be present, it should first be 
removed and the urine should always be filtered before apjjlying 
the test, otherwise subsequent filtration is very difficult. 

Occasionally it happens that urine containing uric acid gives 
no precipitate as above, and a number of other methods have 
been suggested, but as yet we lack a thoroughly trustworth}- and 



34 ANALYSIS OF URINE. 

ready method for clinical work. Hay craft's method has hereto- 
fore been most employed. This is based upon the fact that uric 
acid combines with silver as silver urate ; the silver urate is col- 
lected, dissolved in nitric acid, and the silver is estimated volu- 
metrically b} r Vollard's method. From the amount of silver 
found the amount of uric acid is calculated. Czapek found a 
large error in this method, and Salkowski also regards the process 
as misleading, because the composition of the silver urate is not 
uniform, and Gossage confirms this statement. The methods of 
Fokker-Salkowski and Camerer have been strongly recommended, 
of late. The following method of Hopkins, which is a modifica- 
tion of Fokker's method, has recently been recommended as the 
best to date 1 : — 

Hopkins's Method. — In this process the uric acid and all the 
urates are precipitated by saturation with ammonium chloride, 
which converts them all into urates of ammonium. They are 
then filtered out and the uric acid separated by the action of 
lrydrochloric acid. The final estimation is then made by titra- 
tion with a standard solution of potassium permanganate, which 
is found more accurate than weighing. 

The process, as applied to all urines, normal and pathological, 
is as follows : — 

1. In Normal Urine without Deposit. — (a) To 100 cubic cen- 
timetres of the urine ammonium chloride is added until practi- 
cally saturated ; about 35 grammes are necessary. When a small 
quantit}' of the chloride remains undissolved, even after brisk 
stirring at intervals of a few minutes, saturation is sufficient. 
As the temperature of the urine again rises, from the depression 
due to the process of solution, any residual crystals will, for the 
most part, dissolve ; but there is no necessity for adding more. 

(6) After having stood for two hours, — better with occasional 
agitation, to promote subsidence, — the precipitate produced is 
filtered through a thin filter-paper and washed three or four 
times with saturated solution of ammonium chloride. The 
filtrate should remain perfectly clea-r and bright. 

(c) With a jet of hot distilled water the urate, which will be 

1 Jour. Pathology and Bacteriology, 1S93, vol. i, No. 4, p. 450. 



NDRMAL CONSTITUENTS OF URINE. 35 

somewhat pigmented, is now washed off the filter into a small 
beaker, and heated just to boiling with an excess of hydrochloric 
acid. It is then allowed to stand for the uric acid to separate 
out completely. Two hours is sufficient, if the liquid be cooled. 
The acid is then filtered off and washed with cold distilled 
water. The filtrate should be measured before the washing has 
begun, and 1 milligramme added to the final result for each 15 
cubic centimetres of liquid present. This need never be more 
than from 20 to 30 cubic centimetres. 

The acid is now again washed off the filter with hot water, 
warmed, with the addition of sodium carbonate, till dissolved, 
and the solution then made up to 100 cubic centimetres. Being 
transferred to a flask of sufficient capacity, it is mixed with 20 
cubic centimetres of strong, pure sulphuric acid, and immedi- 
ately titrated with one-twentieth normal potassium-permanganate 
solution. The latter should be added slowly toward the end of 
the reaction, the close of which is marked by the first approach 
of pink color, which is permanent for an appreciable interval. 
Previously, the disappearance of the color will have been instan- 
taneous. The flask should be agitated throughout the operation. 

The standard solution is made by dissolving 1.5Y8 grammes 
of pure potassium permanganate in 1 litre of distilled water. 
Of this, 1 cubic centimetre is equal to 0.00315 gramme of uric 
acid. The addition of 20 per cent, of sulphuric acid to the 
solution produces a temperature suitable to the reaction, and 
no thermometer need be used. 

2. In acid urine containing cystin the author recommends the 
addition of a few drops of strong ammonia, which will obviate 
all difficult} 7 . 

3. In alkaline urine with abundance of phosphates, they 
should be filtered off after complete precipitation by heat. The 
ammoniacal urate comes down more rapidly in alkaline than acid 
urine. The only objection to adding ammonia in all cases is 
its tendency to precipitate the phosphates. 

4. Albuminous urine does not interfere with accurate deter- 
mination of uric acid by this method, but requires a little longer 
digestion with hydrochloric acid. 

5. With highly -pigmented urine the original urate precipitate 



36 ANALYSIS OF URINE. 

is thoroughly digested with alcohol, and after acidification the 
filtrate is gradually heated to boiling, and then digested for some 
time on a water-bath. The separated crj^stals are then thoroughly 
washed. 

In all cases exceedingly accurate results are claimed, and 
the process can be carried out with ease and comparative rapidity. 

Xanthin (C 5 H 4 N 4 O a ). 

This substance contains one atom of oxygen less than uric 
acid, hence its close alliance chemically with the latter. Xanthin 
is present in normal urine, although in very small quantity. 
Neubauer found only 1 gramme in 300 litres of normal human 
urine. When deposited in the urine spontaneously, it forms 
brittle scales of yellowish-white color and of somewhat waxy 
consistence. It is insoluble in alcohol and ether, feebly soluble 
in water, and readily soluble in alkalies, as well as in dilute 
nitric and Irydrochloric acids. Xanthin is a constituent of a 
very rare form of calculus, having thus been met with not to 
exceed half a dozen recorded times, and these always in cases of 
youth. As a urinary sediment it has been encountered more 
frequently. 

Although xanthin is widely distributed throughout the 
economy, having been found in most of the viscera as well 
as in the blood, the conditions which give rise to its increased 
and decreased excretion by the kidneys, as well as its occurrence 
as a urinary sediment, are as yet but little known. Durr and 
Strohmyer state that its amount in the urine is increased by 
sulphur-baths. 

Detection. — When dissolved in dilute hydrochloric acid, upon 
evaporation xanthin separates into hexagonal crystals. When 
evaporated to dryness with nitric acid, a yellow residue remains, 
which turns red with potassium hydrate and reddish violet on 
being heated. 

Allantoin (C 4 H 6 N 4 3 ). 

This substance is obtainable from uric acid by oxidation with 
potassium permanganate (care being taken that the temperature 



NORMAL CONSTITUENTS OF URINE. 37 

does not rise), the potassium permanganate taking up water and 
oxygen, forming allantoin and carbonic acid : — 

2C 3 H 4 N 4 2 + 2H 2 + 2 = 2C 4 H 6 N 4 3 -f 2C0 2 . 

Uric acid. Allantoin. 

Allantoin ciystallizes in colorless prisms, which are soluble 
in hot water, but slightly soluble in cold water, and insoluble in 
alcohol and ether. It is precipitated from its solutions by mer- 
curic salts. Allantoin occurs in mere traces in normal human 
urine, except directty after birth, but it is increased by a meat 
diet, and by administration of tannic acid. It was found by 
Wohler in the urine of newborn calves, and since then b}^ numer- 
ous observers in the urine of newborn infants. Its close chem- 
ical alliance with uric acid is shown by the fact that Salkowski 
found allantoin with urea and oxalic acid much increased in the 
urine of animals (dogs) by the administration of uric acid. 

Detection and Determination. — Allantoin may be separated 
from the urine by precipitation with lead acetate, filtering, pass- 
ing sulphuretted hydrogen through the nitrate, filtering again, 
evaporating the final filtrate to a syrupy consistence, and letting 
it stand for several days. Allantoin then crystallizes out. 

Creatinin (C 4 H 7 N 3 0). 

Creatinin and creatin are both constituents of normal urine, 
and are subject to interchange one into the other, according to 
certain conditions. In alkaline urine creatin appears in greater 
quantity, while the reverse is the case with strongly acid urine. 
Physiologically they may be considered as one body, although 
chemically they differ in the fact that creatin contains H 2 more 
than creatinin, as may be seen by their formulae, — creatinin, 
C 4 H 7 N s O; creatin, C 4 H 9 N 3 2 . Since the urine is usually 
acid, creatinin is generally considered the normal constituent. 

Creatinin is a decided base— probably the strongest in the 
economy — giving a distinctly alkaline reaction with test paper. 
It crystallizes in large colorless prisms, soluble in water and 
alcohol, but almost insoluble in ether. 

Creatinin is a constant constituent of normal human urine, 
being excreted in nearly the same amount as uric acid, — 0.5 to 



38 



ANALYSIS OF URINE. 



0.9 gramme in twenty-four hours (7 to 13 grains). It has been 
generally considered that creatinin of the urine arises from the 
creatin of the muscles, because when animals are fed on creatin 
the creatinin of the urine is increased. But Meissner has shown 
that when creatin is injected into the blood it appears in the urine 
as such unchanged ; and it would therefore appear that the kid- 
neys have not the power of converting creatin into creatinin ; the 
change probably takes place normally in muscles, the creatinin 
entering the blood and being excreted by the kidneys. Bunge, 
however, points out the fact that the relatively small excretion 
of creatinin cannot account for the large amount of creatin of 
the muscles, — 90 grammes. He therefore considers it more prob- 
able that creatinin is ultimately 
converted into urea, the crea- 
tinin of the urine — or creatin, 
if the urine be alkaline — being 
derived from the food. 

Creatinin is excreted in in- 
creased amount upon a meat 
diet, and in diminished quanthry 
by fasting. Clinically it is 
excreted in increased quantity 
in acute diseases, — as pneu- 
monia, the efflorescent stages 
of typhoid and intermittent 
fever, and in some cases of 
diabetes, though not in all. It is diminished in convalescence 
from acute diseases, in advanced degeneration of the kidne} T s, 
and tetanus. In diseases characterized by muscular wasting in 
general, creatinin is usually diminished. 

Detection and Determination. — 1. When a solution of sodium 
nitro-prussiate is added to a dilute solution of creatinin, and 
subsequently sodium hydroxid is added, a red color appears, 
which changes to yellow upon standing (Weyl's test). 2. A so- 
lution of creatinin, as in the urine, acidulated with nitric acid, 
gives, with phospho-molybdic acid, a yellow crystalline precipi- 
tate, soluble in hot nitric acid. 3. With zinc chloride it gives a 
characteristic crystalline precipitate (groups of fine needles) con- 




Fig. 5.— Creatinin Crystals. 
(After Kuhn.) 



NORMAL CONSTITUENTS OF URINE. 39 

sisting of a combination of zinc chloride with creatinin. This 
test is used for quantitative estimation of creatinin. 

The five bodies just considered in detail — viz., urea, uric acid, 
xanthin, allantoin, and creatinin — constitute the chief constit- 
uents of normal urine of the nitrogenous type, or protein deriva- 
tion. In addition to these, however, thio- (sulpho-) cyanic acid 
is found in the urine, in very minute quantities, in the form 
of thiocyanates. 

AROMATIC SUBSTANCES OF THE URINE. 

These comprise four classes : (a) Hippuric acid and similar 
aromatic compounds of glycocin. (6) Combinations of glycu- 
ronic acid with aromatic substances, (c) Aromatic oxy-acids. 
(d) Ethereal sulphates. 

Hippuric Acid (C 9 H 9 N0 3 ). 

Hippuric acid is monobasic and crystallizes either in the form 
of fine needles or four-sided prisms and pillars terminated by two- 
or four- sided beveled surfaces. The typical form is that of a ver- 
tical rhomboid prism. It is colorless, odorless, and of slightly 
bitter taste. It requires 600 parts of cold water to dissolve it, 
but it is much more soluble in hot water and readily so in hot 
alcohol and ether. It is soluble in ammonia and alcohol, but 
insoluble in hydrochloric acid. Hippuric acid is a constant ele- 
ment of normal urine, although present in small amount, — 0.5 to 
1 gramme being excreted by the kidneys in twenty-four hours. 

Hippuric acid is an interesting product in a comparative 
physiological sense, since it forms a connecting link between the 
urine of herbivora, omnivora, and the carnivora ; being present 
in comparatively large amount in the former, much less in the 
second, and absent in the last-named order. It is also interesting 
in itself, as forming one of the best illustrations of synthesis 
occurring in the organism. 

In man the hippurie acid excreted by the kidneys depends 
chiefly upon the character and quantity of food eaten, being in- 
creased by a vegetable diet, — especially by certain fruits, as cran- 
berries, prunes, green gages, etc. The administration of benzoic 
acid, oil of bitter almonds, toluol, cinnamic acid, benzylamin, 



40 



ANALYSTS OF URINE. 



phenylpropionic and kinic acids also cause an increased excre- 
tion of hippuric acid. On the other hand, an animal diet greatly 
decreases its excretion, although it does not disappear from the 
urine upon an exclusive meat diet. Clinically we find an in- 
creased excretion of hippuric acid in diabetes and chorea, as well 
as in acute febrile processes. Numerous observations go to show 
that hippuric acid is formed in the kidneys ; synthesis, as a rule, 
failed after removal of these organs. 




Fig. 6.— Hippuric-Acid Crystals. (After Peyer.) 

Detection and Determination. — 1. Evaporate the urine with 
nitric acid, and heat the residue in a dry test-tube. If hippuric 
acid be present an odor like that of oil of bitter almonds is 
plainly observable, due to the formation of nitrobenzol. 2. If 
the urine contain an excess of hippuric acid, it may be deter- 
mined by slightly evaporating and feebly acidulating with hydro- 
chloric acid. Upon standing for a few hours the hippuric acid 
crystallizes out and may be recognized by the microscope. The 
hippuric-acid crystals may be readily separated from uric-acid 
crystals by hot water, if the uric acid be present in sufficient 



NORMAL CONSTITUENTS OF URINE. 41 

quantity to interfere with the test. 3. Meissner's method con- 
sists in precipitating carefully 1000 to 1200 cubic centimetres of 
urine with strong baryta-water ; the excess of the latter is re- 
moved by a few drops of sulphuric acid (of which an excess is to 
be avoided) and then filtered. The filtrate, accurately neutral- 
ized with hydrochloric acid, is then evaporated on a water-bath 
to the consistency of a thick syrup, and the neutral residue, 
while still hot, is added to 150 or 200 cubic centimetres of abso- 
lute alcohol in a closed glass vessel. Any succinic-acid salts are 
precipitated together with the chloride of sodium, etc., while the 
hippuric-acid salts remain in solution. After repeated agitation, 
as soon as the precipitate has settled well the alcoholic solution 
is decanted and the alcohol completely driven off on the water- 
bath, the syrupy residue, which on cooling solidifies to a crystal- 
line mass, is put in a closed vessel while it is still hot, acidulated 
with hydrochloric acid, and the hippuric acid extracted by 
shaking with not too small amounts of ether (100 or 150 cubic 
centimetres). After the ether is distilled off, the residue is di- 
luted with water, and heated to boiling with a little milk of lime. 
The hippuric acid separates from the concentrated filtrate, after 
the addition of hydrochloric acid, in beautiful crystalline ro- 
settes ; they can be obtained entirely free from color by treating 
with pure animal charcoal. 

Combinations of Olycuronic Acid. — This body is closely allied to the carbo- 
hydrates, and is apt to be mistaken for sugar in the urine. Normally.it occurs 
in mere traces in urine. It occurs partly in combination with aromatic sub- 
stances. 

Aromatic Oxy-acids. — Of these hydroparacumaric acid or oxyphenylpropi- 
onic acid and oxyphenylacetic acid are found in minute quantities in the urine, 
in combination with potassium. 

Ethereal Sulphates. 

In 1851 Stadeler discovered, on distilling the urine with di- 
lute sulphuric acid, small quantities of phenol or carbolic acid in 
the distillate. Hoppe-Seyler showed that phenol is not present 
in the urine in a free state, but as a compound, from which it 
is liberated by sulphuric acid in distillation. In 1876 Baumann 
discovered that this compound consists of an ethereal compound 
of phenol and sulphuric acid. Baumann also discovered the pres- 



42 ANALYSIS OF URINE. 

ence of other like ethereal sulphates in the urine, consisting of 
compounds of the radicle HS0 3 , sometimes incorrectly termed 
sulphonates. The most important of this series are the ethereal 
potassium sulphates of phenol, creosol, catechol or pyrocatechin, 
indole, and skatole. These compounds are present in the urine of 
herbivora more abundantly than in carnivora or omnivora ; but 
they are present in the urine of all animals in smaller or larger 
quantities. They originate in two wa} T s : (a) from aromatic sub- 
stances in food, and (b) in the intestine as the result of putrefac- 
tive changes. In man, whose food contains but little aromatics, 
the origin of these ethereal sulphates is probably chiefly, if not 
entirely, in the intestines, as above indicated ; since, if putrefac- 
tion in the intestines be arrested, these substances disappear 
from the urine. The proportion of the ethereal sulphates to the 
total sulphates of the urine is about 1 to 10. 

Hoppe-Seyler found the ethereal sulphates in the urine in ex- 
cess under the following circumstances : 1. In deficient absorp- 
tion of the normal products of digestion, such as occurs in peri- 
tonitis and tuberculosis of the intestine, because the products of 
digestion undergo putrefactive changes, and the putrefactive 
products are absorbed. 2. Diseases of the stomach, in which 
the food long remains in the stomach and undergoes fermenta- 
tive changes, always result in excess of ethereal sulphates in the 
urine. 3. Putrefactive processes outside the alimentary canal, 
putrid cystitis, putrid abscesses, putrid peritonitis, etc., have 
the same effect. The amount of ethereal sulphates is, moreover, 
in all cases proportional to the severity of the putrefaction, and 
is increased by the retention and diminished by the discharge of 
putrid matter ; as, for instance, in opening an abscess. By these 
and other observations it has been conclusively established that 
the best guide to the occurrence and amount of putrefaction in 
progress in the economy is the relation of the ethereal sulphates 
to the total sulphates. 

Phenol-Potassium Sulphate (C 6 H 5 OS0 3 K). 

The above is the form in which phenol or carbolic acid exists 
in the urine. Phenol (C 6 H 6 0) was found to be one of the in- 
testinal products of putrefaction by Baumann, as already stated. 



NORMAL CONSTITUENTS OF URINE. 43 

This is absorbed and excreted in the above form ; some of the 
sulphate comes from tyrosine, which passes through the stages 
of paracreosol and paraox3 T benzoie acid before conversion into 
the phenol salt (Baumann). 

After the use of carbolic acid, externally or internally, the 
amount of phenol sulphate in the urine is increased ; two sub- 
stances are formed by splitting up of carbolic acid, called pyro- 
catechin and hydroquinon. These become, in alkaline urine, dark 
brown upon exposure to the atmosphere ; producing the well- 
known color of the urine in " carboluria." 

Detection. — 1. Distil the urine acidulated with sulphuric acid. 
Phenol appears in the distillate ; acid bromine-water, a precipitate 
of tribromophenol appears, — deep yellow. 2. Warm the distillate 
with Millon's reagent and a cherry-red color results. 3. Add 
ferric chloride to the distillate and a deep-violet color results. 

Determination. — Approximate results may be obtained as fol- 
lows : 100 cubic centimetres of urine are concentrated over a 
water-bath to 20 cubic centimetres volume. Sulphuric acid is 
added in such quantity as to represent 5 per cent, of the mixture. 
Distil until the distillate is no longer rendered cloudy by addition 
of bromine-water. The distillate is filtered, if necessary, and 
colored a permanent light yellow with bromine-water. The mixt- 
ure is allowed to remain two or three days at a moderate tem- 
perature. A precipitate of tribromophenol (C 6 H 2 Br 3 OH) forms 
and is collected on a weighed filter, washed with water, and dried 
in an exsiccator over sulphuric acid to constant weight; 100 
parts of tribromophenol correspond to 28.4 parts phenol. 

Indoxyl-Potassium Sulphate (C 8 H 6 NO.S0 3 K). 

(indican ?) 

Indole (C 8 H 7 N), the basis of the above substance, is formed 
in the intestines ; indoxyl, as a radicle thereof, has the formula 
C 8 H NO, which, united with S0 3 K, forms the indoxyl-sulphate 
of potassium of the urine. It occurs in white tablets and plates, 
soluble in water, but sparingly soluble in alcohol. By oxidation 
indigo blue is formed therefrom. Indoxyl-potassium sulphate 
has received the erroneous name of indican, under the mistaken 



44 ANALYSIS OF URINE. 

belief that it is identical with vegetable indican. But the latter 
substance is a glucoside, and only resembles the former in the 
fact that one of its decompositional products is indigo blue. 

The blue, green, and some red urines met with in disease 
probably owe their colors to this salt in different stages of oxi- 
dation. It is excreted in excess on an exclusive meat diet, 
or the ingestion of indole. Clinically an increased excretion of 
this substance by the kidneys is observed in Addison's disease, 
cholera, carcinoma of the liver, chronic phthisis, central and 
peripheral diseases of the nervous system, typhoid fever, dys- 
entery, and the stage of reaction in cholera. In obstructive 
diseases of the small intestine its excretion is enormously in- 
creased. In general, the appearance of large quantities of this 
substance in the urine implies that abundant albuminous putre- 
faction is progressing in some part of the sj^stem. Sometimes, 
as urine is undergoing decomposition changes, a bluish-red pel- 
licle, consisting of microscopic crystals of indigo blue and red, is 
seen, — due to decomposition of the indoxyl-sulphate. 

Detection. — 1. McMunn's method: Equal parts of urine and 
li3 T drochloric acid with a few drops of nitric acid are boiled 
together, cooled, and agitated with chloroform. The chloroform 
is colored violet, and shows an absorption band, before Z>, due to 
indigo blue, and another after D, due to indigo red. 

2. Jaffe's method: Mix 10 cubic centimetres of strong hydro- 
chloric acid with an equal volume of urine in the test-tube, and 
while shaking add drop by drop a perfectly -fresh saturated solu- 
tion of chloride of lime, or chlorine-water, until the deepest at- 
tainable blue color is reached. The mixture should next be agi- 
tated with chloroform, which readily takes up the indigo and 
holds it in solution, and the quantity present may be approxi- 
mately estimated according to the depth of the color. 

If the urine contain albumin, it should be removed before 
applying these tests, otherwise the blue color often arising from 
the mixture of hydrochloric acid and albumin after standing may 
prove misleading. 

3. Pour 4 cubic centimetres of hydrochloric acid into a small 
flask, and while stirring add from 10 to 20 drops of urine. If 
the proportion of indigo be about normal, the resulting color 



NORMAL CONSTITUENTS OF URINE. 45 

will be rather light yellow ; if in excess, the acid will turn violet 
or blue, — the more intense will be the color in proportion to the 
quantity present. If no coloration appear after waiting a minute 
or two, there is no excess, however deep a color may subsequently 
appear. 

In addition to those considered, the urine contains three 
other ethereal sulphates, — viz., creosol-potassium sulphate, cate- 
chol-potassium sulphate, and skatoxyl-potassium sulphate. These 
for the most part are present in minute amounts, and possess the 
same significance as those considered. 

URINARY PIGMENTS. 
Normal Urobilin. 

Urobilin is the chief coloring agent of normal urine, although 
it is not the exclusive one, as shown by spectroscopic analysis. 
Normal urobilin is a dark-brown, amorphous, rather resinous 
substance, sparingly soluble in water, but readily dissolved by 
alcohol, ether, chloroform, acids, and acidulated water, as well as 
by solutions of sodium, potassium, or ammonium hydroxid. 

The origin of urobilin is still the subject of some difference 
of opinion. Formerly, it was believed that bilirubin, entering 
the intestines with the bile, was acted upon by nascent hydrogen 
resulting from putrefaction, and as a result it constituted a re- 
duction product, which Maly considered identical with hydro- 
bilirubin. It was also supposed that the pigment of the faeces 
was partly absorbed, carried to the kidneys, and there excreted. 
Hydrobilirubin, stercobilin, and urobilin were considered identi- 
cal, but spectroscopic examinations prove them to be different. 

McMunn regards the formation of urobilin as the result of 
oxidation processes by means of nascent oxygen, either in the 
intestines or elsewhere, rather than due to reduction processes. 
He bases this view principally on the fact that, by the action of 
hydrogen peroxide on acid hsematin, he is able to prepare an 
artificial product, which shows the same spectroscopic appear- 
ances as normal urobilin. The question, then, whether sterco- 
bilin and urobilin are products of reduction or oxidation is still 
unsettled. It is important to remember, however, that urobilin 
may originate either from bile-pigment or from blood-pigment. 



46 ANALYSIS OF URINE. 

Certain facts point to the inference that stercobilin and uro- 
bilin originate — at least, to a limited extent — independently. 
Thus : 1. In animals with biliary fistula, while no bile enters the 
intestine, yet the urine still contains urobilin. 2. In Copeman 
and Winston's case of biliary fistula, in which no bile had entered 
the intestine, the feces were uncolored by stercobilin, yet the 
urine still contained urobilin. 3. Some cases recorded by 
Mott would seem to indicate that the formation of urobilin is 
seated in the liver. When destruction of the red corpuscles is 
excessive in the portal circulation, the liver contains an excess 
of iron, and the ferric residue of haemoglobin occurs as urobilin 
in the urine abnormally abundant. 

Urobilin exists in normal urine in small amount, the quantity 
being much increased in acute fevers, — four to five or more times. 
Typhoid and septic fevers, which cause rapid destruction of the 
blood-corpuscles, markedly increase the excretion of urobilin. 
On the other hand, there is diminished excretion of urobilin in 
conditions associated with diminished metamorphosis of red 
blood-corpuscles, as chlorosis and anaemia, in convalescence from 
acute diseases, as well as in hysteria and nervous diseases. It 
is an interesting and highly-important clinical fact that increased 
excretion of urobilin has been observed in intra-cranial haemor- 
rhages, hemorrhagic infarctions, retro-uterine hematocele, and 
extra-uterine pregnancy. 

According to the observations of Lawson, the excretion of 
urinary pigment is much greater in tropical than in temperate 
climates. Thus, assuming the normal unit to be 4.8 in the aver- 
age adult in temperate climates, he found in the tropics that it 
rose to 12 or 14. In pneumonia it has been observed to rise to 
16 and 20 ; in acute rheumatism, from 30 to 32 at the height of 
the disease ; in typhoid fever, from 80 to 100 ; and in a man 
who had inhaled arsenated hydrogen, from 600 to 800. 

Detection. — Upon rendering the urine alkaline by the addition 
of ammonia, and, after filtering, adding some chloride-of-zinc 
solution to the filtrate, a beautiful green fluorescence may be 
observed b}^ reflected light if urobilin be present. The above 
solution furthermore exhibits, with the spectroscope, a dark 
absorption-band between Fraunhofer's lines b and F. 



normal constituents of urine. 47 

Uroerythryn. 
By some this is considered identical with skatole-pigment, but 
McMunn claims for it certain characteristic reactions. It is 
chiefly this pigment which colors the urates a reddish tint, and 
it may be extracted therefrom by boiling alcohol. This solution 
gives two ill-defined bands before F in Fraunhofer's scale. In 
the solid state it becomes green with sodium or potassium hy- 
droxid. The origin of uroerythryn in the economy, as well as 
its relationship to urobilin, have not been determined. 

Urochrom. 
This name was first applied by Thudicum to the body which 
he considered the chief coloring agent in the urine. Urochrom 
is thought by some to consist of impure urobilin. Certain it is, 
at least, that urochrom contains much urobilin. Urochrom 
occurs in yellow scales, which partly dissolve in water, less solu- 
ble still in alcohol, but soluble in ether and dilute mineral acids 
and alkalies. The aqueous solution becomes dark on standing, 
finally changing to a red color, becoming turbid, and depositing 
resinous flocculi. Urochrom is precipitated from its aqueous 
solution by nitrate of silver as a gelatinous mass soluble in 
nitric acid ; acetate of lead gives a white flocculent precipitate. 
Mercuric nitrate gives a white precipitate, wdiich, on boiling, be- 
comes a pale flesh-color, the supernatant fluid appearing rose- 
red. By oxidation there is first formed from urochrom a red 
substance, which corresponds to uroerythrin, and to which the 
red urine of disease often owes its color. 

Other Organic Constituents of Urine. 
Oxalic Acid (C 2 H 2 4 ). — This substance never occurs in the urine in 
a free state, but always in combination with calcium (oxalate of lime), 
which is held in solution by the acid sodium phosphate of the urine. It 
is sometimes absent from the normal urine, though usually present in 
quantity of about 0.1 gramme for twenty-four hours. When present in 
excessive quantities in the urine it is precipitated in the form of oxalate- 
of-calcium crystals. These are distinguished by their form, — quadratic 
octahedra, with a short principal axis, — often termed "envelope crystals." 
Occasionally dumb-bell forms are seen. The origin of oxalic acid in the 
organism is undetermined ; but a close relationship evidently exists be- 
tween it and uric acid. 



48 ANALYSIS OF URINE. 

Succinic Acid (C 4 H 6 4 ) is the third of the series of acids of which 
oxalic acid is the primary. Succinic acid has occasionally been met with 
in the urine, especially after the ingestion of asparagus and asparagin. 

Lactic Acid (C 3 H 6 3 ). — It is doubtful if lactic acid be present in 
normal urine, but it has been found combined with bases after physio- 
logical disturbances and severe muscular labor. In such cases it oc- 
curs as sarcolactic acid. It has been found in trichinosis, acute yellow 
atrophy of the liver, cirrhosis of the liver, diabetes, phosphorus poison- 
ing, rickets, leucocythaemia, osteomalachia, and in animals after extir- 
pation of the liver. 

Fatty Acids. — These are present in normal urine, though in mere 
traces, — 0.008 gramme per day. They consist of formic, acetic, butyric, 
and propionic acids. The excretion of fatty acids by the kidneys is in- 
creased during the process of ammoniacal fermentation. Certain febrile 
diseases cause an increase of these bodies in the urine to 0.06 gramme, and 
in certain diseases of the liver the increase reaches from 0.6 to 1 gramme 
per day. These acids apparently exist in the urine in a free state. 

Olycero -phosphoric Acid (C 3 H 9 P0 6 ) occurs in faint traces in normal 
urine, about 15 milligrammes per litre. It is said to be increased in 
nervous disorders and after chloroform narcosis. 

Carbohydrates. — Much discussion has taken place over the ques- 
tion as to whether grape-sugar is a constituent of normal urine. One 
difficulty in determining this point is the fact that the urine contains a 
number of substances which reduce alkaline solutions of cupric oxide 
the chief of these being uric acid, hippuric acid, pyrocatechin, glycuronic 
acid, and creatinin. Abeles showed, however, that none of these sub- 
stances undergo alcoholic fermentation with yeast, while this does occur 
with the reducing substance of normal urine. Wedenski, by shaking a 
large quantity of normal urine with benzoic chloride, obtained insoluble 
benzoyl compounds of carbohydrates, which give all the reactions of 
grape-sugar. It may therefore be considered as conclusive, as Brucke 
first affirmed, that minute quantities of sugar exist in. normal urine. 

Animal Gum. — This constitutes a product of mucin, and was first 
found in the urine by Landwher ; also in saliva, the synovia, in colloid 
cysts, in chondrin, and in connective tissue. It forms an opalescent 
solution with water ; gives a sticky precipitate with copper sulphate, and 
also with ferric chloride. It is precipitated by alcohol, and does not re- 
duce alkaline solutions of cupric salts. It yields oxalic acid upon treat- 
ment with nitric acid, and lsevulic acid after treatment with hydrochloric 
acid, as does vegetable gum. 

. Milk-sugar occurs in variable quantities in the urine of nursing 
mothers and lesions of the mammary glands. Hofmeister precipitated 
urine with lead acetate and ammonia, filtered, shook the filtrate with 
silver oxide, filtered, decomposed the filtrate with sulphuretted hydrogen 



NORMAL CONSTITUENTS OF URINE. 49 

to get rid of the silver, filtered ; to the final filtrate barium carbonate was 
added, and the mixture evaporated to dryness. Alcohol removed milk- 
sugar from the residue, and characteristic crystals thereof were obtained 
by evaporating off the alcohol. Kaltenbach proved that this was milk- 
sugar by further obtaining therefrom galactose and mucic acid. 

Inosite — This substance has been found in normal urine in small 
quantities by numerous observers. An increased excretion has been noted 
in Bright's disease and in diabetes. It may be detected as follows : 
Several litres of urine, feebly acidified, are completely precipitated with 
acetate of lead and filtered. The filtrate is warmed and precipitated 
with basic lead acetate. After standing forty-eight hours the precipitate 
is collected, washed, suspended in water, and treated with a stream of 
sulphuretted hydrogen ; the lead sulphide is filtered off; uric acid sepa- 
rates from the filtrate after a few hours ; this is also filtered off. The 
solution is then evaporated to a syrupy consistence on a water-bath, and 
absolute alcohol added. The precipitate is dissolved in hot water, and 
three or four times the volume of 90-per-cent. alcohol added. Ether is 
cautiously added till a permanent cloud appears ; the inosite crystallizes 
out, and may be collected. It will then give its characteristic tests, as 
follows: 1. With a few drops of nitric acid on a platinum dish, treated 
with ammonia and calcium chloride, after evaporating to dryness a 
bright red or violet color appears. 2. Add a little mercuric nitrate to a 
solution of inosite, on a porcelain capsule, a yellow precipitate results. 
On gently heating, this becomes red ; on cooling, the color vanishes. 
Proteids, tyrosin, and sugar must be absent. 

Ferments. — Pepsin has been isolated from normal urine by Brucke, 
Sahli, and others. The morning urine is richest in pepsin. The pepsin 
of urine forms peptone and all intermediate proteoses from fibrin, the 
same as does pepsin. Detection : Small pieces of fibrin are first soaked 
in urine until pepsin is absorbed therefrom. If then removed to 0.1 per 
cent, hydrochloric-acid solution they are rapidly digested. Control ex- 
periments, with fibrin not soaked in urine, give negative results. 

Diastase. — Holvotschiner has obtained minute quantities of ptyalin 
or a similar diastatic ferment from urine. 

Rennet. — Helwes and Holvotschiner have both obtained from urine 
traces of a ferment which curdles milk. 

Trypsin. — This ferment is doubtless absent from normal urine. 
Sahli alone, of all investigators, claims to have found it; but his results are 
considered as due to non-prevention of putrefaction in his experiments. 

Mucin. — This is the chief constituent of the mucus of normal urine, 
derived from the muciparous glands of the urinary passages, but not 
from the kidneys. In normal urine, mucin occurs in small amount ; 
but in catarrhal diseases of the urinary tract it is increased, often 
in abundance. In appearance it is viscid, slimy, and tenacious. 



50 ANALYSIS OP URINE. 

Detection: 1. Mucin is precipitated from its solutions by vegetable 
acids, the precipitate being insoluble in excess of the acid. 2. Add to 
one volume of urine three volumes of strong alcohol and let stand for 
several hours. Filter and wash the precipitate with alcohol, and treat 
with warm water. The filtrate containing the mucin is then acidified 
with acetic acid, and if turbidity results it is due to mucin. 

INORGANIC CONSTITUENTS. 

The inorganic constituents of the urine comprise chiefly the 
chlorides, carbonates, sulphates, and phosphates. These occur in 
combination with potassium, ammonium, calcium, and magnesium. 
Small quantities of fluorine, silicic acid, and iron are also present ; 
and free gases, including carbonic acid, nitrogen, and traces of 
oxygen. The total amount of these salts in the urine varies 
from 9 to 25 grammes per day. They are derived from (a) the 
food ingested and (6) from the metabolic processes or tissue- 
changes ; the latter more especially with regard to the sulphates 
and phosphates. The salts of the blood and those of the urine 
are very similar, save that the blood contains but traces of sul- 
phates, while the urine is rich in these salts. 

The sulphates are derived chiefly from the changes occurring 
in the proteids of the body ; the nitrogenous elements of the 
proteids being excreted as uric acid and urea, while the sulphur 
becomes oxidized, forming sulphuric acid, which appears in the 
urine mostly in combination with metallic bases, but also, to 
some extent, in ethereal combinations with organic radicles, 
making up the ethereal sulphates just considered. 

Chlorides. 
The chlorides of the urine consist chiefly of chloride of sodium 
with a small amount of chloride of potassium and ammonium. 
The amount of chlorides excreted by the kidne} T s in the healthy 
adult averages from about 10 to 16 grammes in twent}^-four 
hours, — 6 to 10 grammes of chlorine. The chlorides, therefore, 
next to urea, constitute the principal solid constituent of the 
urine. Chlorine is very widely distributed throughout the 
organism, nearly always in combination with sodium, potassium, 
ammonium, and magnesium. As chloride of sodium it is ex- 
creted with the perspiration, saliva, bile, faeces, and urine. 



NORMAL CONSTITUENTS OF URINE. 51 

In health the excretion of the chlorides by the kidneys varies 
in amount according to the quality and quantit}' of food ingested. 
Thus, upon a liberal salt diet they are largely increased; the 
output representing very closely the amount of chloride of 
sodium taken in. With active exercise there is also increased 
excretion of chlorides by the kidneys, while, on the other hand, 
during repose of the body they are diminished. 

Clinically the excretion of chlorides with the urine is dimin- 
ished in all acute febrile conditions, and especially when attended 
by serous exudations. As a general rule, in such cases there is 
a steady decrease until the crisis of the disease is reached, after 
which they gradually increase. A continued increase of chlorides 
in the urine in febrile states may, therefore, be accepted as an 
evidence of improvement. In pneumonia the chlorides may dis- 
appear from the urine, and their absence, under such circum- 
stances, always indicates a serious condition of the patient. In 
chronic conditions associated with impaired digestion and 
dropsy the chlorides are diminished. In the latter case much 
of the chlorides become stored up in the dropsical fluid in the 
serous cavities and cellular tissues. The chlorides are excreted 
by the kidneys in excess in diabetes insipidus and in the declin- 
ing stages of dropsy after the establishment of diuresis. 

Detection. — 1. The urine is treated with nitric acid and a 
solution of nitrate of silver added. A caseous precipitate soluble 
in ammonia, insoluble in nitric acid, shows the presence of 
chlorides. 

2. The above test may be made available for approximative 
estimation as follows : A standard solution of nitrate of silver, 
1 to 8 (1 drachm to the ounce), is first prepared. Take a glass 
half full of urine, and add a few drops of nitric acid ; then add 
one or two drops of the standard solution of silver nitrate, 
and note the changes. If a white, flaky precipitate occur, 
quickly sinking to the bottom of the glass without diffusing 
through the urine, the chlorides are undiminished. If a simple 
cloudiness appear, readily diffusing throughout the urine without 
the appearance of curdy flakes, the chlorides are diminished to 
0.1 per cent., the normal being 0.5 to 1 per cent. Should no pre- 
cipitate whatever occur, the chlorides are absent. This method, 



52 ANALYSIS OF URINE. 

proposed by Ultzmann, is not satisfactory, and the author pre- 
fers his centrifugal method. (See " Centrifugal Analysis.") 

Determination. — Mohr's Method: Prepare the following solu- 
tions: 1. Standard nitrate-of-silver solution: Dissolve 29.075 
grammes of fused nitrate of silver in 1000 cubic centimetres 
(1 litre) of distilled water; 1 cubic centimetre of this solution is 
equal to 0.01 gramme of sodium chloride. 2. A saturated aque- 
ous solution of neutral potassium chromate. 

Process. — Take 10 cubic centimetres of urine ; dilute with 100 
cubic centimetres of distilled water ; add to this a few drops of 
the potassium-chromate solution. Drop into this mixture from 
a burette the standard nitrate-of-silver solution ; the chlorine 
combines with the silver to form silver chloride in the form of 
white precipitate. When all the chlorides are thus precipitated, 
silver chromate (red) appears, though not while any chloride 
remains in solution. The silver nitrate must, therefore, be added 
until a pink tinge appears. Read off the quantity of standard 
solution of silver used, and calculate therefrom the quantity of 
chlorides in the 10 cubic centimetres of urine tested, and from 
this the percentage. 

Corrections. — 1. A high-colored urine may cause difficulty in 
determining the appearance of the pink tinge. This may be ob- 
viated by diluting the urine to a normal color. 2. One cubic 
centimetre should be subtracted from the total number of cubic 
centimetres of the silver-nitrate solution emplo3 r ed, as the urine 
contains small quantities of certain compounds more easily pre- 
cipitable than the chromate. 3. To obviate such errors the fol- 
lowing modification of the test as advised by Sutton is employed : 
Ten cubic centimetres of urine are measured into a thin porcelain 
dish and 1 gramme of pure ammonium nitrate added ; the whole 
is then evaporated to dryness, and gradually heated over a small 
spirit-lamp to low redness till all vapors are dissipated and the 
residue becomes white. It is then dissolved in a small quantity 
of water, and the carbonates produced by combustion of the or- 
ganic matter neutralized by dilute acetic acid ; a few grains of 
pure carbonate of lime are added to remove all free acid, and 
one or two drops of potassium chromate. The mixture is then 
titrated with deci-normal silver solution (16.966 grammes silver 



NORMAL CONSTITUENTS OF URINE. 53 

nitrate per litre) until the pink color appears. Each cubic centi- 
metre of silver solution represents 0.005837 gramme of salt ; con- 
sequently, if 12.5 cubic centimetres have been used, the weight 
of salt in 10 cubic centimetres of urine is 0.07296 gramme, or 
0.T296 per cent. If 5.9 cubic centimetres of urine are taken for 
titration, the number of cubic centimetres of silver solution 
used will represent the number of parts of salt per 1000 parts 
of urine. 

Liebig's method consists in estimating the chlorine with mer- 
curic nitrate, but it sometimes fails unless very accurately 
manipulated, and, moreover, it often gives erroneous results, and 
therefore it is only referred to here. 

Volhard and Falch Method. — This method depends upon the 
action of soluble sulphocyanides with solutions of silver and 
ferric salts. Soluble sulphocyanides produce in silver solutions 
a white precipitate similar to silver chloride, which is insoluble 
in dilute nitric acid. A like precipitate of sulphocyanide of sil- 
ver with a solution of nitrate of silver is given by the blood-red 
solution of sulphocyanide of iron, and the color of the latter at 
last completely disappears. If, therefore, a solution of sulpho- 
cyanide of potassium be added to an acid solution of nitrate of 
silver, to which a little ferric sulphate has been added, every drop 
of the sulphocyanide solution at first produces a blood-red cloud, 
which, however, quickly disappears again on stirring, while the 
fluid becomes milk-white. It is not until all the silver is pre- 
cipitated that the red color of the sulphocyanide of iron remains 
permanent, and the end of the process is reached. The reaction 
is one of great delicacy ; so that it is equally sensitive as Mohr's 
reaction, while it has the advantage over the latter that titration 
can be conducted in acid urine. 

Solutions Required. — 1. Standard silver solution is made b} r 
dissolving 29.075 grammes of pure silver nitrate in water and 
diluting to 1 litre. Each cubic centimetre corresponds to 10 
milligrammes of chloride of sodium or 6.065 milligrammes of 
chlorine. 

2. Solution of Ferric Oxide. — A cold saturated solution of 
crystallized ferric alum, free from chlorine, or a solution of ferric 
sulphate, which contains 50 grammes of iron oxide to the litre. 



54 ANALYSIS OF URINE. 

3. Standard Sulphocyanide-of- Potassium Solution. — Since 
sulphocyanide of potassium cannot be readily weighed with ac- 
curacy, 10 grammes are dissolved in a litre of water, and this 
solution is standardized by silver solution. Thus 10 cubic cen- 
timetres of the silver solution are measured off, 5 cubic centi- 
metres of the iron solution are added, and then pure nitric acid 
is added drop by drop until the mixture is colorless. If the 
sulphocyanide-of-potassium solution be then allowed to flow into 
it from a burette, each drop at first gives a blood-red color, 
which at once disappears on stirring. When all of the silver is 
precipitated as sulphocyanide of silver, the next drop of the 
sulphocyanide-of-potassium solution gives a permanent red color 
to the fluid, indicating the end of the reaction. If, for example, 
to 10 cubic centimetres of the silver solution 9.6 cubic centi- 
metres of the sulphocyanide-of-potassium solution have been used 
before the red color is permanent, 960 cubic centimetres are 
measured off, and this is diluted with 40 cubic centimetres of 
water to make a litre. Both solutions must now be equivalent, 
which is to be determined by titration. 

Analysis. — Five or 10 cubic centimetres of the urine, after the 
addition of 1 or 2 grammes of nitrate of potassium free from 
chlorine, are evaporated to dryness on a water-bath. The resi- 
due is then heated over a free flame, at first gently, afterward 
strongly, and a white, fused residue remains. Since the nitrous 
acid formed in this process prevents the end reaction, the fused 
saline mass is dissolved in water, acidulated with nitric acid, and 
then the chlorine is precipitated with an excess of the standard 
silver solution. After this mixture has been warmed on a water- 
bath for a time to completely remove the nitrous acid, it is 
allowed to cool ; 5 cubic centimetres of the iron solution are 
added, and then the sulphocyanide-of-potassium solution, equiva- 
lent in strength to the silver solution, is added while constantly 
stirring until the excess of the silver added is precipitated, which 
is known by the permanent red color of the mixture. The dif- 
ference, then, between the number of cubic centimetres of the 
silver and sulphocyanide solutions corresponds to the chlorine 
contained in the urine. If, for instance, at first 12 cubic centi- 
metres of the silver solution were added to 10 cubic centimetres 



NORMAL CONSTITUENTS OF URINE. 55 

of urine, and 4 cubic centimetres of the sulphocyanide solution 
were required to titrate back the excess, the amount of chlorine 
in the urine corresponded to 12 — 4=8 cubic centimetres of 
the silver soluion = 8.0 grammes of sodium chloride or 4.852 
grammes of chlorine in the litre of urine. 

Phosphates. 

The quantity of phosphoric acid excreted by the kidneys in 
the healthy adult ranges from 2.3 to 3.5 grammes in twenty-four 
hours, the average being about 2.8 grammes. Ordinary phos- 
phoric acid (H 3 P0 4 ) is tribasic, containing 3 atoms of hydrogen, 
which may be replaced by a metal. In the urine phosphoric acid 
occurs in combination, in part with the alkaline earths — earthy 
phosphates, and in part with the alkalies — alkaline phosphates. 
The earthy phosphates are insoluble in water, but soluble in 
acids, and consist of phosphates of calcium and magnesium. 
The calcium phosphates are most abundant ; those of potassium 
scanty. They exist in the urine in quantity of about 1 to 1.5 
grammes in twenty -four hours' excretion, — the relative proportion 
being calcium phosphate about 33, and magnesium phosphate 
about 67. In acid urine the earthy phosphates are in solution, 
while in alkaline urine they are precipitated and form a sedi- 
ment more marked if heat be applied. If, therefore, an alkaline 
urine is heated in a test-tube, a precipitate forms, which may be 
mistaken for albumin. It may, however, be distinguished from 
the albuminous reaction by slight acidification, which readily 
dissolves the earthy phosphates. This is a frequent source of 
error in testing for albumin in the urine by means of heat. If 
the acid magnesium phosphate be acted upon by ammonia the 
ammonio-magnesium phosphate is formed, — triple phosphate. 
This appears in the urine as fern-leaf or snow-flake ciystals, or, 
after long standing, in the form of prismatic or " coffin-lid " 
shaped crystals. If urine decompose in the bladder through 
retention and consequent fermentative changes, ammonia is 
liberated from the urea, and the free ammonia unites with the 
acid magnesium phosphates to form the triple-phosphatic ciys- 
tals so characteristic of chronic cystitis. 

The alkaline phosphates of the urine consist of the acid 



56 ANALYSIS OF URINE. 

phosphate of sodium and the phosphate of potassium, that of 
sodium being most abundant and the potassium phosphate 
scanty. These (unlike the earthy phosphates) are readily 
soluble in water and alkaline fluids. The alkaline phosphates 
form the chief bulk of the phosphates of the urine, ranging from 
2.0 to 4.0 grammes in twenty-four hours. As already noted, the 
acidit}' of normal urine depends upon its contained acid sodium 
phosphate, and not upon the presence of a free acid. 

In the blood the alkaline phosphates exist as neutral sodium 
and potassium phosphates ; but, as Ralfe has shown, 1 these are 
changed into acid salts through a decomposition effected by the 
act of secretion, in which the bicarbonates and neutral phos- 
phates in the blood are changed into carbonates and acid phos- 
phates, respectively. The acid salts, in obedience to the law of 
diffusion, pass out in the urine, whilst the carbonates remain in 
the circulation. The excretion of the alkaline phosphates by the 
kidneys varies in health according to the qualit}^ of food ingested, 
being in excess upon an animal diet. 

The phosphoric acid of the urine is derived in part from the 
food and in part from the decomposition of lecithin and nuclein. 
The excretion of phosphoric acid by the kidnej's varies with the 
amount of food taken ; after the midday meal, especially if much 
meat be eaten, it rises, and reaches its maximum in the evening ; 
it falls during the night, reaching its minimum about midday. 

Clinically, the excretion of phosphoric acid by the kidneys 
is diminished in gout, in most acute diseases, in kidney lesions, 
in the intervals of intermittent fever, and during pregnancy. 
The author regards the diminution of phosphoric-acid excretion 
by the kidne} T s almost as constant a feature of the urine in 
Bright's disease and allied lesions of the kidneys as the presence 
in the urine of albumin. 

An increased excretion of eartrrv phosphates accompanies 
diffuse diseases of the bones, — osteomalacia, rickets, etc.; also in 
diffuse periostitis and diseases of the nerve-centres. 

A condition of so-called phosphatic diabetes has been de- 
scribed by Tessier and confirmed by Ralfe and others, in which 
there is a continued excessive excretion of phosphates by the 

1 Lancet, July, 1874. 



NORMAL CONSTITUENTS OF URINE. 57 

kidneys, attended by symptoms somewhat like diabetes, — loss of 
flesh ; aching pains in the lower back and pelvic region ; dry, 
harsh skin ; tendency to boils, with morbid appetite, etc. 

Detection. — 1. The earthy phosphates may be detected by ren- 
dering the urine strongly alkaline with sodium, potassium, or 
ammonia, and gently heating, which cause their precipitation 
in the form of a whitish cloud, that shortly after settles to the 
bottom of the test-glass. The precipitate is dissolved upon the 
addition of acetic acid. 

2. Ultzmann suggests an approximative method with this test, 
as follows : A test-tube 2 centimetres (0.787 inch) wide is filled 
with the urine to the depth of 5.33 centimetres (2.997 inches), to 
which are added a few drops of strong ammonia or potassium 
solution, and warmed over a spirit-lamp until the earthy phos- 
phates separate. After standing fifteen minutes the depth of 
the sediment is measured. If the layer be 1 centimetre (0.3937 
inch) high, the earthy phosphates are present in normal amount; 
if 2 or 3 centimetres in depth they are increased ; but if the 
sediment be only a line or so in depth, they are diminished. 

The Alkaline Phosphates. — 1. First remove the earthy phos- 
phates by precipitation with potassium or ammonia and filter 
them off. Next add to the urine one-third of its volume of 
magnesium fluid. 1 The alkaline phosphates are all precipitated 
in the form of a snowy deposit. 

2. The above test may be made useful for approximative 
estimation, as Ultzmann suggests, in the following manner : To 
10 cubic centimetres of the urine add a third part (say, 3 cubic 
centimetres) of magnesium mixture. There is formed a precipi- 
tate of crystalline ammonium-magnesium phosphate, with which 
comes down an amorphous mass of calcium phosphates. If 
there ensue through the entire fluid a milk}' turbidity, the alka- 
line phosphates are in normal amount ; if we have a copious 
precipitate, which gives the fluid the appearance of cream, 
then there is great increase ; if the fluid remain transparent, or 
only slight turbidity ensue, we have a decrease of the alkaline 
phosphates. 

1 Magnesium fluid contains, of magnesium sulphate and ammonium chloride, 
each 1 part ; distilled water, 8 parts ; and pure liquor ammonia, 1 part. 



58 ANALYSIS OF URINE. 

Determination of Total Phosphoric Acid. — The following solu- 
tions are necessary : — 

1. A standard solution of uranium nitrate is prepared, con- 
sisting of 20.3 grammes pure uranic oxide in 1000 cubic centi- 
metres of distilled water ; 1 cubic centimetre corresponds to 5 
milligrammes of phosphoric acid. 

2. Sodium-acetate solution : 100 grammes of sodium acetate 
are dissolved in 900 cubic centimetres of distilled water, and to 
this 100 cubic centimetres of acetic acid are added. 

3. Saturated solution of potassium ferrocyanide. 
Analysis. — Fifty cubic centimetres of the urine are poured 

into a beaker, and 5 cubic centimetres of sodium-acetate solu- 
tion are added. The mixture is warmed over a water-bath and 
the uranium solution added, drop by drop, as long as a precipi- 
tate falls. If this be not easily recognized, the mixture should 
be stirred, a drop placed upon a porcelain plate, and a drop of 
potassium ferrocyanide added. If a reddish-brown color do not 
appear at the line of contact, the addition of uranium solution 
should be continued, the beaker-glass being again warmed. The 
limit of reaction occurs when all the phosphoric acid has been 
precipitated by the uranium solution. After this is reached, the 
next drop of uranium solution, finding no phosphoric acid, 
forms a reddish-brown precipitate with potassium-ferrocyanide 
solution. The quantity of uranium solution used is next read 
off, each cubic centimetre being equal to 5 milligrammes phos- 
phoric acid, from which can be readily calculated the percentage 
amount in the urine. 

Estimation of Phosphoric Acid Combined with Lime and 
Magnesium. — To determine the phosphoric acid in combination 
with the earths, 200 cubic centimetres of urine are precipitated 
with ammonia, collected after twelve hours on a filter, and 
washed with ammonia-water (1 to 3). The filter is then pierced 
at the point, and the precipitate washed clown with a stream of 
water into a beaker, and dissolved while warm with as little 
acetic acid as possible. Add 5 cubic centimetres of sodium- 
acetate solution, dilute to 50 cubic centimetres, and proceed as in 
preceding analysis. The difference between the total amount of 
phosphoric acid and that in combination with the alkaline earths 



NORMAL CONSTITUENTS OF URINE. 59 

also represents the quantity combined with the alkalies, — alkaline 

phosphates. 

Sulphates. 

The sulphates in the urine are of two kinds (1) ordinary 
neutral sulphates of sodium and potassium, and (2) the ethereal 
sulphates. Since the sodium salts predominate in the economy, 
the sulphate of sodium occurs in the urine in greater quantity 
than the potassium sulphate. The quantity of sulphates ex- 
creted by the kidneys in the healthy adult varies from 1.5 to 
3 grammes per day. The sulphates, being extremely soluble 
compounds, are, therefore, never met with in the urine in the 
form of deposits. 

An increased excretion of sulphates by the kidneys occurs 
after the ingestion of sulphuric acid or its salts, upon active ex- 
ercise, upon an exclusive meat diet, and inhalations of oxygen- 
gas. Clinically an increase occurs in acute fevers, with in- 
creased urea secretion. The most marked increase is noted in 
meningitis, encephalitis, and rheumatism. In general, it may be 
accepted that the excretion of urinary sulphates runs parallel in 
quantit}^ to that of urea. 

Detection. — 1. To 10 cubic centimetres of urine add a few 
drops of hydrochloric acid, then add about 3 cubic centimetres of 
barium-chloride solution ; a white, milky precipitate is formed of 
sulphate of barium. 

2. More simply still, to 10 cubic centimetres of urine in a 
test-tube add one-third the volume of acidulated barium-chloride 
solution, 1 when a white, milky precipitate at once appears in the 
presence of sulphates. 

3. Approximate estimation may be made by the above as fol- 
lows : If a simple, opaque, milky turbidity result, the sulphates 
are present in about the normal amount ; if more opaque, pos- 
sessing the appearance of cream, the sulphates are excessive ; if 
but a light translucent cloudiness result, the sulphates are 
diminished. 

Determination. — (a) The volumetric method is conducted by 
adding to a given volume of urine a standard solution of barium 
chloride as long as precipitation occurs. 
1 Baric chloride, 4 parts ; acid hydrochloric, 1 part; distilled water, 16 parts. 



60 ANALYSIS OF URINE. 

Solutions Required. — 1. A standard chloride-of-barium solu- 
tion : 30.5 grammes of crystallized barium chloride to 1000 cubic 
centimetres of distilled water ; 1 cubic centimetre of this solution 
corresponds to 0.01 gramme of sulphuric acid. 

2. Solution of potassium sulphate, 20 per cent. 

3. Pure hydrochloric acid. 

Analysis. — One hundred cubic centimetres of urine are ren- 
dered acid by 5 cubic centimetres of Irvdrochloric acid, and 
brought to boiling in a flask. The combined sulphates are thus 
converted into ordinary sulphates, and give a precipitate simi- 
larly with barium chloride. The chloride-of-barium solution is 
allowed to drop into the mixture as long as any precipitate oc- 
curs, the mixture being heated before each addition of barium 
chloride thereto. After adding 5 to 8 cubic centimetres of the 
standard solution, allow the precipitate to settle ; pipette off a 
few drops of the clear, supernatant fluid into a watch-glass ; add 
to it a few drops of the standard barium solution. If any pre- 
cipitate occur, return the whole to the flask and add more barium 
chloride ; again allow the precipitate to settle and test as before ; 
continue thus until no more precipitate is formed on the addition 
of barium-chloride solution. 

Excess of barium chloride should be avoided ; when only a 
trace of excess is present, a drop of the clear fluid removed 
from the flask gives a cloudiness with a drop of potassium- 
sulphate solution placed on a glass plate over a black ground. 
If more than a cloudiness appear, too large a quantity of 
barium chloride has been added, and the analysis must be 
repeated. 

From the quantity of barium chloride used, the percentage 
of sulphuric acid in the urine is calculated, — 1 cubic centi- 
metre of barium-chloride solution corresponding to 0.01 gramme 
of S0 3 . 

(b) Gravimetric determination is best conducted as suggested 
by Salkowski. This consists in washing the precipitate of barium 
sulphate obtained by adding barium chloride to a known volume 
of urine ; 100 parts of sulphate of barium correspond with 34.33 
parts of sulphuric acid (S0 3 ). 

Analysis. — One hundred cubic centimetres of urine are taken 



NORMAL CONSTITUENTS OF URINE. 61 

in a beaker ; this is acidified with 5 cubic centimetres of hydro- 
chloric acid. Chloride of barium is added till no more precipita- 
tion occurs. The precipitate is collected on a small filter of known 
ash, and washed with hot distilled water till no more barium 
chloride occurs in the filtrate, i.e., until the filtrate remains clear 
after the addition of a few drops of hydric sulphate. Then wash 
with hot alcohol, and afterward with ether. Remove the filter 
and incinerate with its contents in a platinum crucible. Cool 
over sulphuric acid in an exsiccator; weigh, and deduct the 
weight of the crucible and filter ash ; the remainder is the weight 
of barium sulphate formed, from which the S0 3 is readily calcu- 
lated, — 100 parts of barium sulphate corresponding with 34.33 
parts of S0 3 . 

Correction. — As carried out above, a slight error occurs in 
the analysis from the formation of a small quantity of sulphide 
of barium. Correct as follows : After the platinum crucible has 
cooled add a few drops of pure sulphuric acid (H 2 S0 4 ). The 
sulphide is converted into sulphate. Heat again to redness and 
drive off the excess of sulphuric acid. 

(c) Salkowski's method of estimating the combined sulphuric 
acid— i.e., the amount of S0 3 in ethereal sulphates — is as follows : 
100 cubic centimetres of urine are mixed with 100 cubic centi- 
metres of an alkaline barium-chloride solution, which is a mixture 
of two volumes of solution of barium hydrate with one of barium 
chloride, both saturated in the cold. The mixture is stirred, and 
after a few minutes filtered ; 100 cubic centimetres of the filtrate 
(=50 cubic centimetres of the urine) are acidified with 10 cubic 
centimetres of hydrochloric acid, boiled, kept at 100° C. on a 
water-bath for an hour, and then allowed to stand till the pre- 
cipitate has completely settled ; if possible, it should be thus 
left for twenty-four hours. The further treatment of this pre- 
cipitate (= combined sulphates) is then carried out as in the 
last case [see (6)]. 

Calculations. — Two hundred and thirty-three parts of barium 
sulphate correspond to 98 parts of H 2 S0 4 , 80 parts of S0 3 , or 
32 parts of S. To calculate the H 2 S0 4 , multiply the weight of 
barium sulphate by ^^ = 0.4206 ; to calculate the S0 3 , multiply 
by ^ == 0.34335 ; to calculate the S, multiply by ^ == 0.13734. 



62 ANALYSIS OF URINE. 

This method of calculation applies to the gravimetric estimation 
both of total sulphates and of combined sulphates. 

(d) To obtain the amount of preformed sulphuric acid, sub- 
tract the amount of combined S0 3 from the total amount of 
S0 3 . The difference is the preformed S0 3 . 

Example. — One hundred cubic centimetres of urine gave 0.5 
gramme of total barium sulphate; this multiplied b} T ^3% =0.171 
gramme = total S0 3 . Another 100 cubic centimetres of the 
same urine gave 0.05 gramme of barium sulphate from ethereal 
sulphates; this multiplied by / 3 °^=0.017 gramme of combined 
S0 3 . Total S0 3 — combined S0 3 =0.171 — 0.071 = 0.157 
gramme of preformed S0 3 , 

Carbonates. 

Carbonate and bicarbonate of sodium, ammonium, calcium, 
and magnesium are present in minute quantities in fresh urine 
of alkaline reaction. The ammonium carbonate maybe found in 
large quantity as a result of alkaline decomposition of the 
urine. The carbonates of the urine are derived from the food, 
from lactic, malic, tartaric, succinic, and other vegetable acids in 
the food. If the urine contain much carbonates when voided it 
is turbid, or soon becomes so upon standing, and upon sedimen- 
tation the precipitate is that of calcium carbonate usually asso- 
ciated with phosphates. Carbonate of lime constitutes the basis 
of urinary calculus of great rarity in the human subject, very 
frequent, however, in herbivora. 

Detection. — The presence of carbonates in the urine maj^ be 
revealed by the evolution of colorless gas, upon the addition of 
acid, and this gas renders baiyta-water turbid. 

Determination. — The following method of Marchand may be 
employed for estimating the free carbonic acid of the urine : 
One hundred cubic centimetres of urine are placed in a glass 
flask, closely fitted with a doubly-perforated cork. Through one 
opening a tube is passed, which dips into the urine, and at the 
other end is connected with a tube containing some quicklime. 
Through the other opening in the cork one arm of a doubly-bent 
tube is passed ; this arm does not dip into the urine. The other 
arm is introduced into an empty flask through a tightly-fitting 



NORMAL CONSTITUENTS OF URINE. 63 

cork. This flask is connected by a similar tube with a second 
flask filled with clear baryta-water, and this with a third and 
fourth filled with baryta-water. 

The urine is heated to 100° C. over a water-bath ; any por- 
tions boiling over go into the empty flask. The carbonic acid 
comes off and forms a white precipitate of barium carbonate in 
the flasks filled with baryta-water. Air is then drawn through 
the apparatus, any carbonic acid in the atmosphere being 
removed by the quicklime. The carbonate of baryta formed is 
collected on a filter, washed with distilled water, dissolved in 
hydrochloric acid, precipitated again by sulphuric acid, and 
weighed as barium sulphate. From the quantity thus obtained 
the amount of carbonic acid in the urine can be calculated : 
196.65 parts of barium carbonate correspond to 232.62 parts of 
barium sulphate and 44 parts of carbonic acid. 

(6) The total carbonic acid may be similarly estimated after 
'strongly acidifying the urine with hydrochloric acid. 

The combined carbonic acid is the difference between the total 
and the free carbonic acid. 

Other Inorganic Constituents. 

Iron occurs in the urine in small quantities, hut its combination is 
yet unknown. Free ammonia occurs in traces, greatly increased in 
putrefactive changes of the urine. Hydrogen dioxide was first shown 
in the urine by Schonben. It exists in small amount, and, so far as 
known, is without special signification. It is detected by tetra-paper, 
which, if immersed in its solution, will show the presence of ozone by 
taking a blue color. 2. Dilute indigo solution is bleached by dioxide of 
hydrogen in the presence of iron-sulphate solution. 

Gases. — The urine contains small quantities of gases. Carbonic 
acid, 4 to 9 volumes free gas ; 2 to 5 combined. Oxygen, 0.2 to 0.6 
volume ; and nitrogen, 0.7 to 0.8 volume. The gases of the urine may 
be withdrawn by the air-pump. 

CENTRIFUGAL ANALYSIS. 
The chemical constituents of the urine, both normal and ab- 
normal, may be estimated by the centrifugal method, and very 
excellent, as well as rapid, results may thus be obtained. The 
method followed by the author consists in throwing out of solu- 
tion the chemical constituents of the urine desired to measure, 



64 



ANALYSIS OF URINE. 



and estimating the quantity of the insoluble precipitates in bulk 
percentage. For this purpose the author has devised a set of 
percentage tubes, which will be found convenient for estimating 
not only the chemical constituents of normal 
urine, but also such products of abnormal 
urine as pus, albumin, etc. These per- 
centage tubes — shown in the figure — are 
graduated in tenths of a cubic centimetre up 
to 10 cubic centimetres. The lower portion 
of the tubes being drawn out in conical form, 
fractions of the first three cubic centimetres 
may be more accurately read and measured. 
Above the graduated scale the tubes possess 
sufficient capacity for the reception of the 
reagents ordinarily required to precipitate 
the urinary constituents to be estimated. 1 
The following is the author's method of con- 
ducting centrifugal estimations of some of 
the inorganic constituents of the urine : — 

Chlorides. — The percentage tubes are 
filled to the 10-cubic-centimetre mark with 
the urine to be tested ; a few drops of nitric 
acid are added to prevent precipitation of 
the phosphates, and then the tubes are filled 
to the 15-cubic-centimetre mark with the 
standard nitrate-of-silver solution (5j to Jj). 
The tubes are next closed and inverted 
several times, until the urine and the re- 
agents are thoroughly mingled. The tubes 
are next placed in the centrifuge and re- 
volved until the sediment is thoroughly 
packed, when the quantity in bulk per- 
centage may be read off from the graduated 
scale on the sides of the tubes. From a 
considerable number of observations the author finds that the 
bulk percentage of chlorides in normal urine thus obtained 

1 Eimer & Amend, of 205 and 211 Third Avenue, New York, manufacture 
and supply the author's percentage tubes for centrifugal analysis. 



fE-1 



Fig. 7.— Author's 
Percentage Tube 



NORMAL CONSTITUENTS OF URINE. 65 

ranges from 16 to 18 per cent. Variations from the normal 
range are quickly indicated, and the degree of variation is 
definitely measured. 

Phosphates. — The gross quantity of the urinary phosphates 
are readily determined by the centrifugal method in a similar 
manner. Thus, the percentage tubes are filled to the 10-cubic- 
centimetre mark with the urine to be tested, and then the mag- 
nesium mixture 1 is added to the 15-cubic-centimetre mark. The 
tubes are closed and inverted several times, until the urine and 
reagents are thoroughly mingled. The tubes are then placed in 
the centrifuge and revolved until precipitation is complete, when 
the bulk percentage may be read off from the scale. 

The chlorides and phosphates precipitated as just described 
form comparatively heavy sediments, which are deposited by the 
centrifuge in about one minute. In order, however, to insure 
uniform results, it is found best to leave the tubes in the centri- 
fuge for three minutes, when the sediments will be found to have 
packed so solidly that only long-continued revolutions cause 
further changes in the reading. With the author's electric cen- 
trifuge it is advised to revolve the tubes uniformly three minutes, 
at moderate speed, before reading the quantity of chlorides and 
phosphates. One thousand revolutions per minute, continued 
for three minutes, give the author's standard results for chlorides, 
phosphates, and sulphates. 

The bulk percentage of total phosphates in normal urine 
determined as just described will be found to range from 8 to 12 
per cent. It may be observed that frequent and wide variations 
in the amount of urinary phosphates are more common than with 
any other urinary constituents. Quantitative centrifugal analysis 
can only be carried out satisfactorily with the electric centrifuge, 
because hand power cannot give the same uniform and definite 
rates of speed as electric power. 

Sulphates. — These are estimated as insoluble salts of barium, 
as follows : The percentage tubes are filled to the 10-cubic-centi- 
metre mark with the urine to be tested ; the acid barium-chloride 



1 The magnesium mixture consists of ammonium chloride and magnesium 
sulphate, aa 1 part ; distilled water, 8 parts ; and liquor ammonia, 1 part. 



66 ANALYSIS OF URINE. 

mixture is next added to the 15-cubic-centimetre mark; 1 the 
tubes are then inverted a number of times, until the urine and 
reagents are mingled. The tubes are then placed in the centri- 
fuge and revolved for three minutes, when the bulk percentage 
of total sulphates may be read off, the range of which in normal 
urine will be found about 1 per cent. The rule followed by the 
author with his electric centrifuge is as follows : The chlorides, 
phosphates, and sulphates are sedimented in the percentage tubes 
by continued revolutions at moderate speed for three (3) minutes. 

The term moderate speed, wherever applied to the author's 
centrifuge, means 1000 revolutions per minute. 

The author has found this method to give excellent approxi- 
mate results for practical work, and the advantages of the 
method are that it can be carried out very rapidly and the 
variations from the normal standard are definitely measured. 
Centrifugal analysis may be extended to practically include all 
urinary constituents. Analj T sis for chlorides, phosphates, and 
sulphates are here described, both to illustrate the method and 
on account of the great practical value of being able so readily 
to approximately estimate these highly-important constituents. 
The author hopes soon to furnish methods and standards for 
centrifugal estimation of most, if not all, the remaining constitu- 
ents of the urine. 

1 The acid barium-chloride solution is composed of 4 parts baric chloride, 1 
part hydrochloric acid, and 16 parts distilled water. 



SECTION III. 

ABNORMAL URINE. 

Proteids. 

The four proteids of the blood — viz., serum-albumin, serum- 
globulin, fibrin, and haemoglobin — are met with in the urine in 
various pathological conditions of the kidneys, the blood, or the 
system at large. Other proteids are sometimes met with in the 
urine which do not exist in the blood, such as egg-albumen upon 
the liberal ingestion of eggs as food, and, under certain con- 
ditions, also peptone. Finally, certain proteoses are met with in 
the urine in pathological conditions, the more prominent of which 
are pro-albumose, deutero-albumose, and hetero-albumose. 

Albuminuria. 

The chief clinical interest with regard to proteids in the urine 
will probably always centre about serum-albumin. While albu- 
min is doubtless the most common of all the constituents of mor- 
bid urine, it still remains a debated question if it be present in 
the urine in health. No doubts can further exist that the urine 
occasionally contains a variable — usually small — but distinct 
amount of albumin when the kidneys present no appreciable 
alterations of structure ; but, as will be shown, albuminuria 
often arises from causes aside from the kidneys themselves. 
Albuminuria, therefore, cannot be proved to be a condition of 
health, so long as the kidneys alone are considered ; yet, the ab- 
sence of renal lesions would seem to be the chief, if not indeed 
the only, condition sought to be established by many advocates 
of a so-called physiological albuminuria. 

Albumin belongs to the class of colloids which do not crys- 
tallize, and under ordinary conditions do not penetrate animal 
membranes ; but alterations from the normal conditions, as in the 
integrity of the basement membrane, in the quality of the albu- 
min itself, or in the pressure to which they are both subjected, 

(67)' 



68 ANALYSIS OF URINE. 

may result in transudation. It is altogether probable that most 
forms of albuminuria are referable to causes corresponding to 
one or more of the above-named conditions. In other words, al- 
buminuria may be clue (1) to changes in the kidneys themselves, 
which impair the integrity of the structures between the vessels 
and the excretory channels of the organs ; (2) alterations in the 
quality of the blood which render its serum-albumin more diffu- 
sible ; (3) alterations in the degree of blood-pressure. Albumi- 
nuria may depend upon one or, indeed, all three of the above con- 
ditions. 

Clinical Significance. — 1. The more common form of albu- 
minuria, as well as the most serious in its clinical significance, is 
that depending upon pathological conditions of the kidneys. The 
most frequent of these are inflammatory and degenerative changes 
in the renal structure, and include the whole class of disorders 
commonly grouped together under the term of Bright's disease. 

It is impossible always to estimate the gravity or progress of 
renal changes by the quantity of albumin present in the urine. 
Sometimes, however, as in acute inflammatory conditions, when 
the amount of albumin ranges high, — 1 per cent, by actual weight 
or more, — the quantity may be taken as a rough gauge of the ex- 
tent of the lesions as well as the progress of the same from day 
to day. The same may be said of certain degenerative changes 
in the kidneys, notably of amyloid disease. This, however, by 
no means applies to all diseases of the kidneys, for, indeed, in 
certain renal diseases of the most serious character, — interstitial 
nephritis, — not only is the quantity of albumin in the urine 
usually small, but it is often temporarily, and even occasionally, 
absent throughout. The quantity of albumin in the urine, 
therefore, is not a safe guide as to the gravity of the situation in 
diseases of the kidneys, especially in cases attended by moderate 
or even very slight grades of albuminuria. 

2. The second class of albuminurias depend upon changes in 
the constitution of the blood, which so alters the diffusibility of 
its albumin as to permit it to pass into the renal tubules. The 
hsemotogenic causes of albuminuria have been most ably ex- 
pounded by Semola, and, although he probably claims too wide 
a range for these causes, there remains no just reason to doubt 



ABNORMAL CONSTITUENTS OF URINE. 69 

their existence. We often meet with such albuminuria in anaemia, 
and in strumous and enfeebled individuals, when no lesions of 
the kidneys can be made out. The effect of certain poisons upon 
the blood probably so alters that fluid as to permit of tran- 
sudation of its albumin into the renal tubules. The effects, also, 
of some infectious fevers — micro-organisms in the blood — no 
doubt seriously alters the constitution of the circulating fluid, 
so that transudation of albumin is the rule, while the kidnej^s do 
not always become damaged. 

3. The third form, disturbances of the circulation, may bring 
about albuminuria without inducing structural changes in the 
kidneys, provided they be not too long continued. Circulatory 
disturbances, in order to induce albuminuria, must include the 
renal vessels. In nature they must consist of acceleration of 
the arterial current or slowing of the venous current, in either 
case resulting in increased blood-pressure. Probably this cause 
is responsible for the majority of that large class of cases of 
so-called " physiological or functional albuminurias." This is 
most marked upon prolonged or fatiguing muscular exercise. 
Leube found albumin in the urine in 16 per cent, of soldiers 
after prolonged march, and Chateaubourg gives the percentage 
as even higher. A similar result sometimes occurs after the 
application of cold to the surface of the body ; the blood being 
driven to the interior, the renal vessels become overfilled and 
albuminuria often results. Again, in some derangements of 
the nervous system, which interfere with the vasomotor-nerve 
regulation of the renal vessels, temporary albuminuria is not 
an uncommon result. Albuminuria from increased blood-press- 
ure is readily demonstrable by experimentation in the following 
ways: 1. By pressure upon the renal veins. 2. Ligature of the 
aorta below one kidney, and extirpation of the other. 3. Com- 
pression of the trachea. The quantity of albumin in the urine 
from disturbances of the circulation is for the most part small. 
It may be but temporarily present, or it may become a permanent 
condition, depending upon the continuance of the cause. Thus 
we may have temporary albuminuria after a seizure of epilepsy 
which soon after the attack subsides, or when depending upon 
organic disease of the heart it becomes permanent. 



TO ANALYSIS OF URINE. 

Finally, albuminuria often owes its origin to two or even all 
three of the causes just considered. In fevers, for instance, all 
the described causes of albuminuria are sometimes present. We 
have, for instance, accompanying changes in blood-pressure, and 
when long continued the febrile state is apt to induce structural 
changes in the renal epithelium, while profound changes in the 
constitution of the blood are often induced by fevers, more espe- 
cially the acute infectious ones, which without doubt are the 
active cause of albuminuria. 

It remains to consider the significance of a form of albumi- 
nuria which is often intermittent in character, to which Pavy's 
" Cyclic Albuminuria" and Moxon's " Albuminuria of Adoles- 
cence " doubtless belong. In a large percentage of these cases 
the albuminuria is intermittent ; if not, usually it is remittent ; the 
intermission or remission occurring during rest, as at night. 
On rising in the morning the urine is often free from albumin, 
but soon after rising, and especially upon exercising, the urine 
contains albumin, which may or may not wear away toward 
evening. A large percentage of these cases is observed in 
youths and young adults. 

In another class of these cases the albuminuria is more con- 
stant, and if an intermission occur it is usually measured by 
weeks or months instead of hours. In these cases the age of 
the patient is less constant, although the albuminuria is still most 
common before middle age. 

For the most part all these cases possess certain features in 
common : 1. The quantity of albumin in the urine is small, usually 
ranging from one-half to one-tenth or two-tenths of one per cent. 
2. The urine either contains no renal casts or very few perfectly 
hyaline ones. 3. The specific gravity of the urine is somewhat 
above the normal standard, — 1024 to 1030. 4. Evidences of car- 
diac and general vascular changes of a permanent nature are 
absent. 5. Close observation will usually reveal evidence of 
some local or general impairment of the functions, as measured 
by the standard of vigorous health. 

The causes of this group of albuminurias are identical with 
those already considered, only operating perhaps in milder de- 
grees. To changes in the renal structures, alterations in the 



ABNORMAL CONSTITUENTS OF URINE. 71 

quality of the blood, or abnormal increase of blood-pressure, — to 
one or more, or all of these combined, we may with great prob- 
ability refer every case of albuminuria as to its essential cause 
or causes. 

It will be seen, from the preceding considerations, that albu- 
minuria is a symptom of the most variable clinical significance, 
and therefore, in itself, should never be accepted as proof of 
the presence of renal disease. As has been truthfully said, " this 
was the error of former times." It can only be positively as- 
serted that albuminuria is the result of renal changes when it is 
accompanied by those products in the urine which are a conse- 
quence of renal lesions, such as casts, epithelium, etc. On the 
other hand, it must be remembered that albumin in notable 
quantity is not present in health}^ urine. On the whole, it will 
be safer to accept albuminuria as an evidence of an existing ab- 
normal state, the gravity of which must be determined by its 
accompanying symptoms. The author holds that so-called func- 
tional albuminuria forms no exception to the above rule, inas- 
much as he has never met with a case of albuminuria in which 
the patient did not present more or less evidence of departure 
from the normal balance of perfect health, either local or general. 

It is only necessary here to allude to the occurrence of albu- 
min in the urine derived from sources other than the kidneys. 
Such albuminuria has been variously termed adventitious, false, 
or accidental. In such cases the urine on leaving the kidneys is 
perfectly normal ; but, meeting with the products of inflamma- 
tory changes in the urinary passages, — the renal pelvis, ureters, 
bladder, or urethra, — it becomes albuminous. As a rule, in such 
cases, the source of the albumin may be determined by chemical 
and microscopical investigation, together with local symptoms. 

Detection of Albumin in the Urine.— 1. Heat: Boiling the 
urine constituted the first test employed to detect albumin, by 
Contugno (1710). The more common method of application of 
this test is in conjunction with nitric acid. A test-tube of ordi- 
nary size is filled half full of the suspected urine, and heat is 
applied until boiling occurs throughout the whole. If a precipi- 
tate occur, it consists either of albumin or earthy phosphates. 
A few drops of nitric acid are next added, and if the precipitate 



72 ANALYSTS OF URINE. 

remain undissolved it is due to the presence of albumin. If, on 
the other hand, the precipitate disappear upon the addition of 
the acid, it consists of the earthy phosphates, and the urine is 
free from albumin. In testing, the acid should be added in small 
quantity, at first, — say, 2 to 5 drops, — and the urine should then 
be re-boiled. If now no precipitate occur, acidulation should be 
continued until precipitation occur or a limit of acidification be 
reached of about 15 to 20 drops. Some prefer to reverse this 
order, and first acidify the urine before applying the heat. 

The heat and nitric-acid test is subject to certain errors. 
Thus, if there be little albumin present and the acid be in excess, 
the albumin may combine with the acid, forming a soluble acid 
albumin, — syntonine, — which is not precipitated by boiling. If, 
on the other hand, the acid be insufficient to distinctly acidify 
the urine, and if the phosphates be in excess, a part only of the 
basic phosphates may be acidified, while the albumin may com- 
bine with the remainder, forming a soluble alkali albuminate, 
which will not be precipitated by boiling. The heat and acid 
test throws down albumin, globulin, and mucin, and upon cooling 
albumose separates, if present. No reaction occurs with peptone, 
vegetable alkaloids in the urine, or with the urates. If the urine 
contain the pine acids, as sometimes occurs after the use of 
cubeb or copaibae, these may cause slight precipitation by this 
test, which may be mistaken for albumin. The ready solubility 
of this precipitate in alcohol distinguishes it from albumin. 

Various modifications have been suggested, with the view of 
avoiding the mucin reaction which sometimes undoubtedly occurs 
with this test, such as first boiling the urine and then very faintly 
acidifying with nitric acid, or by employing acetic instead of 
nitric acid in quantity not to exceed 2 drops. Such modifica- 
tions, however, are not to be depended upon in eliminating the 
occasional mucin error, as will appear by a study of the chemistry 
of mucin reactions. 

2. The Author's Method. — Have at hand a solution of chloride 
of sodium (table-salt), prepared by saturation and filtering, so 
that it is perfectly clear. First raise the specific gravity of the 
urine about 10 or 15 degrees by the addition of a little of the 
sodium-chloride solution. Next fill an ordinary test-tube to 



ABNORMAL CONSTITUENTS OF URINE. 73 

about two-thirds with the urine, add 1 or 2 drops of strong 
acetic acid, and boil the upper inch or so of the urine about half 
a minute over a spirit-lamp. Examine in a good light, and if 
albumin be present it will appear in the upper boiled portion of 
the urine as a more or less pronounced milk-like turbidity, 
according to the quantity present, the lower or unboiled portion 
remaining perfectly clear, in strong contrast. This test possesses 
all the sensitiveness of the heat and acid test for albumin, and 
avoids the mucin reaction. The author advises the above modi- 
fication of the heat and acid test when dealing with minute 
quantities of albumin; with large amounts of albumin the old 
method may be followed. 

3. Nitric-Acid Test. — This test is applied according to Hel- 
ler's method, as follows : Upon a column of pure nitric acid in a 
test-tube the suspected urine is gently floated, so that the column 
of urine and that of acid are about an inch in depth. In order 
to accomplish the above without mixing the acid and urine, the 
test-tube should be held in an inclined position and the urine 
slowly delivered along the inside of the tube, so that the urine 
may flow gently down and overlay the acid. If albumin be 
present, an opalescent zone will be observed at the point of con- 
tact between the acid and the urine, which becomes more or less 
pronounced according to the quantity of albumin present. If no 
change be perceptible upon careful examination in a good light, 
the tube should be set aside and re-examined in half an hour, 
because, when only a trace of albumin is present, twenty to 
thirty minutes may elapse before the zone of coagulated albumin 
becomes visible. 

In concentrated urines with this test the acid is apt to pre- 
cipitate the amorphous urates in the form of a light, rather 
brownish cloud, which may be taken for albumin. The cloud of 
precipitated urates, however, does not appear at the point of 
contact between the acid and the urine, but higher up, within the 
urine itself; moreover, it is more diffused than the albuminous 
zone, and spreads downward through the urine. The precipi- 
tated urates disappear upon the application of gentle heat. 

If the urine contain mucin in excess, a light cloud may come 
into view toward the surface of the urine with this test. It will 



74 ANALYSTS OF URINE. 

be remembered that mucin is soluble in strong nitric acid, but is 
precipitated by the same in dilute form, and therefore the mucin 
reaction always occurs high up in the strata of urine which con- 
tains the acid well diluted. If the urine contain the pine acids 
a reaction may occur with this test somewhat similar to that of 
albumin, though usually less defined. The precipitate due to 
oleo-resins is soluble in alcohol, which distinguishes it from 
that due to albumin. 

The nitric-aCid test precipitates all modifications of albumin, 
acid and alkaline, as well as albumose. On the other hand, rt 
gives no reaction with peptone or the vegetable alkaloids. 

4. The Ferrocyanic Test. — This test is exceedingly simple 
and rapid in application, as follows : Into the bottom of a clean 
test-tube is poured 15 to 30 drops of acetic acid, then about two 
or three times that amount of solution of potassium ferrocyanide 
(1 to 20) is added, and the two thoroughly mingled by shaking 
the tube. The urine is next added, to the depth of two-thirds 
of the test-tube. If albumin be present it will be precipitated 
throughout the whole volume of the urine in the form of a more 
or less milk-like, flocculent cloud, according to the quantity of 
albumin present. The ferrocyanic test applied by the above 
method avoids the mucin reaction, and precipitates all modifi- 
cations of albumin, acid and alkaline. On the other hand, it 
gives no reaction with phosphates, urates, peptones, the vege- 
table alkaloids, or the pine acids. This test may also be applied 
as follows : Fill an ordinary test-tube half full of urine, and add 
a drachm or so of potassium-ferrocyanide solution (1 in 20). 
After thorough mingling of the urine and reagent, add a few 
drops (10 to 15) of acetic acid, and if albumin be present it 
will come plainly into view. This is a most trustworthy test, if 
applied by either of the above methods, and it may be depended 
upon for the detection of albumin in the urine, either in large 
or small amounts, without further corrections or precautions. 
Any precipitate produced by this test, when applied as above, 
is albumin, and nothing but albumin. 1 

1 It is improper to apply this test by previous acidification of the urine, be- 
cause it is only by adding the ferrocyanide solution to the urine first or with the 
acid that the latter is prevented from precipitating the urinary mucin. 



abnormal constituents of urine. 75 

Other Tests for Albumin. 

The last few years have greatly contributed to the number of tests for 
albumin in the urine ; the more prominent of those brought forward are the 
following : — 

5. Potassio-Mercuric Iodide Test. — This solution was first proposed by Tanret 
as a most sensitive test for albumin. The formula is as follows : Potassium iodide, 
3.32 grammes ; bichloride of mercury, 1.35 grammes ; acetic acid, 20 cubic cen- 
timetres ; distilled water to 100 cubic centimetres. The potassium iodide and 
mercuric chloride should be separately dissolved in water, and the solutions 
mixed ; the resulting reagent is the double iodide of mercury and potassium, to 
which the acetic acid is added, and the whole made up to 100 cubic centimetres 
with distilled water. As thus prepared the test is applied by the contact method ; 
the reagent, being of specific gravity of about 1040, is introduced into the test- 
tube first, and the urine allowed to overlay it in the usual manner. 

The test may also be applied by keeping the acid and the mercuric-iodide 
solution separate. The urine is then acidified, first with acetic acid, and the rea- 
gent added to half a test-tubeful of urine, and if albumin be present it is imme- 
diately caused to fall out of solution in a white cloud, more or less pronounced, 
according to the quantity present. 

The test responds to all modifications of albumin, also to peptone and the 
proteoses, as well as the vegetable alkaloids and pine acids. All reactions, how- 
ever, other than with albumin, the pine acids, and mucin, disappear upon gently 
heating. This test is one of great sensitiveness in bringing to light minimal 
traces of albumin. 

6. Picric Acid. — This test has been strongly advocated by Sir George John- 
son, of London. The test is made by saturation, — 6 or 7 grains to the ounce of 
boiling distilled water. Upon a column of urine four inches deep in an ordinary 
test-tube is gently floated the reagent, and in consequence of its low specific 
gravity it only mixes with the upper layer of urine. As far as the yellow color 
of the picric-acid solution extends, the coagulated albumin renders the mixture 
turbid, forming a contrast with the clear urine below. There must be an actual 
mixture, not mere contact of the urine with picric acid. This test precipitates 
albumin, peptone, mucin, proteoses, as well as the vegetable alkaloids, all of 
which, save mucin, are dissolved by heat. 

7. Sodium Tung state. — This test was suggested by Dr. George Oliver as a most 
sensitive reagent for albumin. The solution is made by mixing equal parts of 
sodium-tungstate solution (1 to 4) and saturated solution of citric acid (10 to 6). 
Dr. Oliver applies the test by the contact method. This test precipitates, in 
addition to albumin, peptone, mucin, and occasionally the urates. It gives 
no reaction, however, with the alkaloids, and all precipitates, save those due 
to albumin and mucin, are dissolved by gentle heat. 

8. Acidulated Brine Test. — This test was suggested by Roberts, and is prepared 
by mixing together a pint of saturated solution of sodium chloride and 1 fluid- 
ounce of strong hydrochloric acid, and filtering. The test is applied by the usual 
contact method, the reagent being introduced into the test-tube first, and the 
urine gently floated thereupon. 

9. Nitric Magnesium Test. — This test, also suggested by Roberts, is composed 



76 ANALYSIS OF URINE. 

of 1 ounce of strong nitric acid and 5 ounces of saturated solution of magnesium 
sulphate. This is claimed to be more sensitive than the nitric-acid test, and is 
applied by the contact method. 

10. Phenic- Acetic- Acid Test. — This test was brought forward by Millard as the 
most sensitive of all albumin reagents. The formula is as follows : Acid phenic 
glacial (95 per cent.), 3ij ; acid acetic (C.P.), 3vij ; liquor potassae, £>vj. This 
test is applied in the usual contact manner by overlaying the reagent with the sus- 
pected urine. In addition to precipitating albumin, this reagent throws down 
peptone, mucin, alkaloids, and the pine acids, — the peptone and alkaloids being 
dissolved upon the application of heat. 

11. Trichloracetic- Acid Test. — This solution is prepared by simply saturating 
distilled water with the crystals of trichloracetic acid (about §ss to §j of water). 
The test is applied by the contact method, and delicate results are claimed for 
this reagent. 

12. Heynsius's Test. — The urine is rendered strongly acid with acetic acid ; a 
few cubic centimetres of saturated solution of sodium chloride are added, and 
the mixture boiled. The presence of albumin is shown by the appearance of a 
flocculent precipitate. 

13. Heide?ilang , s Test. — This test simply consists in adding to the suspected 
urine a little solid metaphosphoric acid, and, if albumin be present, coagulation 
occurs in the form of a white precipitate. 

14. Acetic Acid and Sodium Sulphate. — Acidulate the urine strongly with acetic 
acid ; add 1 drachm of the strongly acid urine to 1 drachm of a strong solution 
of sodium sulphate and boil. If albumin be present a permanent precipitate will 
result. 

15. Biuret Test. — The urine is treated with caustic potassium, and a dilute 
solution of cupric sulphate is added, drop by drop, by means of a pipette. If 
albumin be present, the resulting cupric peroxide (a green precipitate) is dis- 
solved, and the fluid assumes a reddish-violet color. This test reacts with albu- 
min, albumose, globulin, and peptone, — the latter substance, however, giving a 
red, not violet, color. 

16. Millon , s Reaction. — Add to 1 drachm of the urine 10 minims of Millon's 
reagent, and heat. If albumin be present in considerable quantities, a white 
precipitate will appear, which will become red when heated. If only a trace of 
albumin be present, no precipitate is formed, but the fluid becomes red. This 
reaction is common to all the monohydroxol-benzol derivations, and is ambigu- 
ous, since the reaction can be obtained from bodies of the aromatic series. 

17. Xanthoproteic Reaction. — Add to the sample of urine concentrated nitric 
acid and boil. Let the liquid cool, and then add ammonia. If albumin be 
present an orange color is produced. 

About ten years ago the author made some study of the then 
newer tests for albumin 1 in the urine, especially including Nos. 5, 
6, and 7. Very recently he has subjected practicall} 7 the whole 

1 " The Comparative Value of the Newer Tests for Albumin in the Urine," 
Journal of the American Medical Association, January 19, 1884. 



ABNORMAL CONSTITUENTS OF URINE. 77 

series to a most crucial examination, with a view of determining 
their practical value for clinical purposes. The conclusions 
reached are as follow : While many of these later tests — notably 
5, 6, 7, 8, 9, 10, and 11 — are exceedingly delicate reagents for 
albumin, greatly exceeding in sensitiveness the older methods, — 
as, for instance, with heat and nitric acid, — yet their increased 
sensitiveness is nearly always obtained at the expense of trust- 
worthiness. Without exception, the tests named give a reaction 
with substances in normal urine, or with substances in abnormal 
urine other than albumin. Furthermore, some of these reac- 
tions cannot be distinguished from the albuminous reaction 
without further testing, and even in some cases without an 
appeal to some other test. Sir William Roberts claims that 
the most common source of fallacy is with mucin. While the 
author believes that mucin is not the exclusive source of error, 
especially with those reagents for which unusual sensitiveness 
is claimed, — nucleo-albumin, as well as proteids of no grave 
pathological significance, being often responsible for these reac- 
tions, — yet he believes that the mucin reaction is positively 
avoided in but two tests in the whole series, — viz., in Nos. 2 and 
4. If a pure solution of mucin be prepared and normal albumin- 
free urine be heavily charged with this solution, the following 
reactions may be observed : (a) Upon the addition of a few 
drops of nitric acid to such a urine in a test-tube a distinct, 
albumin-like precipitation at once appears, which boiling, how- 
ever long, fails to remove. If the process be reversed and heat 
be first applied, and subsequently the acid be added, the result 
is precisely the same. (6) If now we follow the principle of 
test No. 2, and first raise the specific gravity of the urine by a 
saline such as sodium chloride to 1035, and then add one or two 
drops of acetic acid and boil, no precipitate whatever appears, 
because, while acetic acid is a sensitive precipitant of mucin, 
yet in solutions rich in salines mucin will not be precipitated by 
acetic acid even in very considerable quantity, (c) If next the 
muciparous urine be submitted to test No. 3, — Heller's nitric- 
acid method, — a very distinct reaction results, (d) If the urine 
be subjected to No. 4, we find that the ferroc} T anic solution acts 
as does the saline (sodium chloride) and prevents the precipita- 



78 ANALYSIS OF URINE. 

tion of the mucin b}^ the acetic acid, and no precipitate results. 
(e) If next the muciparous urine be subjected to tests 5, 6, 7, 8, 
9, 10, 11, 12, 13, and 14, a very distinct reaction will become 
visible in most, if not in all, cases, but more especially marked, 
perhaps, in 5, 6, 7, 8, 10, 11, and 13. As a rule, the more highly 
acid the urine (normal acidity), the more sharp will be the reac- 
tion, and this corresponds with the oft-mentioned fact that these 
highly-sensitive tests give reactions with most urines of high 
specific gravitjr. It is evident from the above observations that 
our methods of testing for albumin in the urine, even with some 
of the older routine tests, need revision. 1 

While, doubtless, it is desirable that we should possess tests 
for albumin of somewhat greater sensitiveness than the old and 
somewhat crude method of boiling the urine, yet, after all, 
extreme delicacy of reaction is altogether a matter of secondary 
consideration, as compared with accurac}', because, when the 
quantity of albumin in the urine is very slight, resort must 
necessarily be had to other means than the presence of traces 
of albumin in the urine, in order to be able to establish a posi- 
tive diagnosis of renal disease. Notwithstanding the above 
facts, much unnecessary confusion and uncertainty in our 

1 Many of the newer tests for albumin call for the previous acidification of 
the urine by some acid. This necessarily precipitates the mucin of the urine, 
if present in excess, and the addition of the reagent usually intensifies this- 
mucin reaction. Now, it is well known that in all highly-concentrated urines 
there is present a more or less excess of mucin, and it seems irresistible to con- 
clude that in this class of tests the faint reaction noted so commonly in urines 
of high specific gravity is very often due to mucin rather than to minimal traces 
of albumin. Any acid will thus act with mucin unless special precautions be 
taken to prevent it. The strong mineral acids, by the contact method, become 
diluted by the strata of urine near the plane of contact, and this dilution permits 
precipitation of the mucin, if present in excess. The vegetable acids need no 
dilution, but throw out mucin at once, either when mixed with the urine or upon 
contact, in the latter case at the point of contact. For these reasons the author has, 
from long experience, come to be somewhat suspicious of tests for albumin which 
require previous acidification of the urine, when searching for minute traces of 
albumin. If we wish to avoid the mucin reaction, it can only be done in the pres- 
ence of albumin precipitants, by first charging the urine with some salt that pre- 
vents precipitation of the mucin ; and while the albumin precipitant may thus 
act if mingled with the urine, by previous acidification of the urine it usually 
only intensifies the mucin reaction. 



ABNORMAL CONSTITUENTS OF URINE. ?9 

present methods have been caused by the multiplication of 
tests for albumin in the urine whose chief claim for recognition 
is that of great sensitiveness of reaction rather than that of 
trustworthiness. On the other hand, it is not the newer methods 
that are alone responsible for all the errors that are encountered 
in searching for albumin in the urine. Indeed, the very oldest 
method in use, — that with heat and nitric acid, — unfortunately, 
requires precautions and corrections so perplexing, in order to 
be absolutely reliable, that authors themselves are by no means 
agreed as to the safest method of its application. 

18. Tests in Paper Form. — According to the suggestion of 
Dr. George Oliver, of Harrogate, 1 a number of the tests named 
have been prepared and used in paper form. This is accom- 
plished by saturating chemically inert filtering-paper with solu- 
tions of the albumin reagents, and with citric acid and then 
drying. The papers are then cut into slips of convenient size 
for testing, and may be carried about in the pocket-case for use 
at the bedside of the patient. In testing, the following method 
is followed : Into a small test-tube containing one drachm of dis- 
tilled water are dropped a reagent paper and one charged with 
citric acid. After agitation for a minute or so the test-papers 
are removed and the solution is ready for testing. The urine is 
now added, and the test may be conducted either by a mixture 
of the two or by the contact method, of which Dr. Oliver advises 
the latter. 

Dr. Oliver now advises the use of two reagents only for al- 
bumin, viz., the ferrocyanic and potassio-mercuric papers. The 
former of these will be found trustworthy, and of very great 
convenience in clinical work in the hospital wards or at the 
bedside, if applied in accordance with the principles laid down 
by the author in using the ferrocyanide test, i.e., by using the 
reagent first and the acid last. 

Method of Testing fop Albumin in the Urine. — If the quantity 
of albumin in the urine be large, the use of any of the first four 
tests described will unmistakably reveal its presence. It is only 
in searching for the smaller quantities of albumin that errors are 

1 Bedside Urine Testing. London, 1SS5. 



80 ANALYSIS OF URINE. 

likely to be encountered in testing ; since a number of substances 
are often present in the urine which may give precipitates strongly 
resembling those due to albumin in small amounts. 

In searching for albumin in the urine a test should be selected 
for routine work which is trustworthy, ready of application, re- 
quiring the fewest possible precautions, and possessing reason- 
able delicacy of reaction. In these respects, No. 4, — the ferro- 
cyanic test, — is the most desirable in the list described. This 
test is recommended for routine work because it requires the 
fewest precautions, while in point of delicacy it is at least equal 
to nitric acid or heat, in whatever form applied. This test gives 
no reaction with peptone, mucin, the vegetable alkaloids, urates, 
or the pine acids, while it sharply reacts with all modifications 
of albumin, whether acid or alkaline. 1 

It has been stated that the ferroc} T anic test occasionalh' pre- 
cipitates the urates of the urine as a source of error. The author 
has used the test daily for over ten years without meeting such 
reaction. Those who still prefer to work with the old method of 
heat and acid will do well, when dealing ivith minute quantities of 
albumin, to follow the course advised in No. 2, thereby avoiding 
the possible mucin reaction. 

Test No. 3, Heller's nitric-acid method, is one of considerable 
delicacy. It will, however, precipitate mucin, which slowly 
settles down to the point of contact between the two fluids; and 
when it is remembered that in the presence of minute quantities 
of albumin it requires twenty or thirty minutes to bring out the 
latter, it will be seen that there is no certain method of distin- 
guishing between the two. The same may be said with refer- 
ence to its behavior with urates, save that the latter ma}^ be made 
to disappear by heat. 

1 Over ten years since, the author claimed (Journal of the American Medical 
Association, January 19, 1884) that the ferrocyanic test for albumin was the 
most ready and trustworthy of the list. Again, in 1886, the author wrote 
(Bright's Disease and Allied Affections of the Kidneys, p. 43) : "Subsequent use 
has shown me that this test is the least liable to errors of all tests for albumin in 
the urine, if properly applied." The fact that within the past five years the 
ferrocyanic test has been given the preference in many of the leading laborato- 
ries and clinics in Continental Europe over all others only confirms the author's 
views both then and now. 



ABNORMAL CONSTITUENTS OF URINE. 81 

Finally, in searching for albumin in the urine, it is sometimes 
useful to have a test of extreme delicacy of reaction purely for 
negative purposes. As such, the potassio-mercuric iodide solu- 
tion is probably the most desirable. If, for instance, no reaction 
be obtained by this reagent, it is certain that no albumin what- 
ever is present in the urine; and, furthermore, the urine is abso- 
lutely free from all known proteids. The author strongly ad- 
vises the future disuse of all albumin tests, from No. 5 to No. 14 
inclusive, for clinical purposes, — save for negative or differential 
information, — for his experience has shown him that they are 
undoubtedly misleading and untrustwortlrv. 

Determination of Albumin in the Urine. — The quantity of 
albumin in the urine is most accurately determined by the 
" Gravimetric Method," as follows : 100 cubic centimetres of the 
urine are treated with a mixture of equal parts of ferrocyanic 
solution (saturated) and acetic acid, which is added drop by 
drop until all the albumin is precipitated, after which the fluid is 
passed through a filter of known weight. The precipitate on the 
filter is next washed successively with water, alcohol, and ether, 
and dried at a temperature of 120° C. The filter, with its con- 
tained albumin, is next weighed, and the difference in weight due 
to the precipitate is the weight of the albumin in 100 cubic 
centimetres of urine. 

The above process is altogether too tedious for clinical pur- 
poses, and moreover it is, strictly speaking, unnecessary. It 
serves no practical purpose to know the exact number of grains 
of albumin in a given specimen of urine, because the severity of 
the disease cannot be accurately gauged by such knowledge. 
On the other hand, it is of great practical utility to be able to 
estimate the relative quantity of albumin in the urine from day 
to day, in order to be able to determine the progress of the dis- 
ease and the results of treatment. 

It is much to be regretted that we possess no standard method 
of expressing the quantity of albumin in the urine, in conse- 
quence of which, as Dr. Tyson correctly observes, " There is 
much carelessness of expression among physicians in speaking 
of the quantity of albumin found in a given specimen of urine." 
Thus, bulk measure hy precipitation is often spoken of as per- 



ANALYSIS OF URINE. 



Hi 



centage amount, and hence we often hear of urines containing 
50 and even 75 per cent, of albumin, when, as a matter of fact, 
the urine never contains to exceed 3 or 4 per cent, by actual 
weight. The expression, percentage, therefore, 
should be qualified by the statement of the 
measurement, whether it be by bulk or weight. 

Esbach's Method. — This test is made by 
means of a standard graduated glass tube or 
albuminometer, as shown in the figure. The 
process is as follows : The following standard 
solution is prepared: Picric acid, 10 grammes; 
citric acid, 20 grammes; distilled water, to 1000 
cubic centimetres (1 litre). Fill the albumi- 
nometer tube with the urine to the letter U, then 
add the test solution to B, close the tube with 
the stopper and invert several times, until the 
urine and the test solution are thoroughly 
mixed. Stand the tube in a rack for twenty- 
four hours and then read off the number of 
grammes of albumin to the litre, as will be 
indicated by the number on the side of the 
tube on a level where the albumin settles. If 
it be desired to know the percentage of albumin 
in the urine instead of the number of grammes 
per litre, remove the decimal point" one figure to 
the left; thus 5 grammes per litre would be 0.5 
per cent, of albumin. It will be observed that 
Esbach's albuminometer tubes are so graduated 
that their highest range is 1 grammes per litre, 
0.7 per cent, of albumin. If, therefore, the urine 
be highly albuminous, it should be diluted with 

one or two volumes of water before testing, and 
Fig. 8.— Esbach's o1 

albuminometer. the product multiplied by two or three, accord- 
ing as the volume is doubled or trebled. These 
albuminometer tubes are supplied by Eimer & Amend, of Third 
Avenue, New York, at moderate cost. 

In order to get immediate results the author places these 
albuminometer tubes in the centrifugal machine, when the albu- 



ABNORMAL CONSTITUENTS OF URINE. 83 

min is precipitated in three or four minutes. It is found that, 
as soon as the albumin settles so that the fluid above is clear 
by centrifugation, the instrument reads practically the same as 
standing for twenty-four hours. Centrifugation is also found to 
possess the following advantages: It obviates the occasional 
failure of the albumin to settle in the bottom of the tube ; the 
specifie gravity of the urine does not materially influence the 
uniform settling of the albuminous sediment. 

The Author's Centrifugal Method. — With the author's elec- 
tric centrifuge this method can be carried out very rapidly 
(within five minutes), and the results are all that are desirable 
for practical purposes. Process : The percentage tubes (see p. 
64) are filled to the 10-cubic-centimetre mark with the urine to be 
tested, and 3^ cubic centimetres of potassium-ferrocyanide solu- 
tion (1 in 10) are added; lj cubic centimetres of acetic acid are 
next added, and the reagents and urine are thoroughly mingled 
by closing and several times inverting the tubes. The tubes are 
next placed in the centrifuge and revolved until all the albumin 
has settled, leaving the fluid above perfectly clear. The bulk 
percentage of albumin is then read off", each y 1 ^ cubic centimetre 
representing 1 per cent, bulk measure of albumin. 

Esbach's method is supposed to measure the amount of dry 
albumin by weight, but, unfortunately, Esbach's reagent (picric 
acid) throws out and measures peptones, mucin, the proteoses, 
and practically all the proteids of the urine, and, therefore, the 
author finds that it is subject to almost constant and wide 
errors. 

The author's centrifugal method, on the other hand, throws 
out and measures all the albumin, and practically nothing else. 
In carrying out the centrifugal method it will be found neces- 
saiy, if the urine be very highly albuminous, to dilute with one 
or two volumes of water, and multiply the result, accordingly, 
by two or three. 

In taking the measurement of albumin by the centrifugal 
method the following rule should be observed, to insure uniform 
results : Leave the percentage tubes in the centrifuge until all the 
albumin is fully precipitated and the urine above is perfectly 
clear, then read the amount. This method quickly and definitely 



84 ANALYSIS OF URINE. 

determines the amounts of albumin in the urine from day to 
day, and more minutely measures the degree of increase or 
diminution than is possible with Esbaeh's method, because the 
unit of Esbach's albuminometer is 1 gramme, which, if measured 
by the author's percentage tubes, would correspond to nearly 14 
per cent, (or 14 units). 

Proteoses. 

These substances are the intermediate products in the hydra- 
tion of proteids, the final products being peptones. In the 
body they are formed by the action of the gastric and pancreatic 
juices, and they may be formed artificially b} r heating albumin 
with water, — more readil}' by dilute mineral acids or sulphuretted 
steam. The}- correspond to the propeptone of Schmidt-Mulheim, 
and to the A-peptone of Meissner. They are uncoagulable by 
heat, are precipitated but not coagulated by alcohol ; they all 
respond to the biuret reaction, and are precipitated by nitric 
acid, the precipitate thus formed being dissolved by heat, but 
re-appearing upon cooling. 

These substances may be subdivided into albumoses, globu- 
loses, vitelloses, caseoses, myosenoses, depending upon the pro- 
teid from which the}' are formed. The albumoses and globuloses 
are absent from normal urine, but appear in the urine under a 
number of abnormal conditions. 

Albumosuria. — The albumoses are of two varieties : hemi- 
albumoses, or those convertible b} T further digestive action into 
hemi-peptone, and anti-albumoses, or those similarly converted 
into anti-peptone. Albumoses have also been classed according 
to their solubilities, as follows : (a) Proto-albumose ; soluble in 
cold and hot water, and in saline solutions. They are precipi- 
tated as are globulins, b}- saturation with sodium chloride and 
magnesium sulphate. (6) Hetero-albumose ; insoluble in water ; 
soluble in 0.5 to 15 per cent, sodium-chloride solutions in the 
cold, but precipitable by heat at 65° C, the precipitate being 
readily soluble in dilute acid or alkali. It is precipitated by 
alcohol as is other albumoses, but, unlike them, it is partly con- 
verted into an insoluble dys-albumose. Hetero-albumose is pre- 
cipitated by dialyzing out the salines from its solutions, and, 



ABNORMAL CONSTITUENTS OF URINE. 85 

like proto-albumose, it is precipitated by saturation with salines. 
Proto- and lietero- albumoses constitute the first products of 
the hydration of proteids, and have hence been called primary 
albumoses. (c) Deutero-albumose is soluble in cold and hot 
water, is not precipitated from its solutions b} r saturation with 
sodium chloride or magnesium sulphate, but it is precipitated by 
strong solutions of ammonium sulphate. It is not precipitated 
by copper sulphate, and only gives the nitric-acid reaction (char- 
acteristic of albumoses) in the presence of excess of saline. It 
is therefore, in reactions, nearest to peptones of the albumoses ; it 
is an intermediate stage in the conversion of primary albumoses 
into peptone. 

Clinical Significance. — Albumose, like peptone, is found in 
pus ; but, unlike the latter, it is also present in the blood, most 
notably so during digestion. An albumose was first discovered 
in the urine by Bence Jones in a case of osteomalacia, and in a 
like case since by Kuhn. Virchow has found this albumose in 
the medulla of bones in osteomalacia, while Fleischer found it 
in the medulla of normal bone. Senator has found albumoses 
in a number of cases in the urine, — viz., tertiary syphilis, hemi- 
plegia, double pneumonia, diphtheria, carcinoma, and muscular 
atrophy. Hoppe-Seyler has found it in a number of cases of 
atrophy of the kidneys. Lassar has found it in the urine of 
people rubbed with petroleum, while Oertel has met with it in 
a few cases after severe exertion. Albumose and peptone are 
both found in the urine of animals when injected into their cir- 
culation. Deutero-albumose so closely resembles peptone in its 
reactions that it is often mistaken for the latter substance. Its 
distinction from peptone will be considered in connection with 
peptonuria. The clinical significance of albumosuria, so far as 
our present knowledge extends, is very indefinite; so that prac- 
tical conclusions in connection with its presence in the urine are 
as yet lacking. In the few diseases in which it has been noted, 
its appearance, under similar circumstances, has subsequently 
been found inconstant. 

Detection. — The proteoses are known by their solubilities 
and reactions, as follows : Proteo-albumose, soluble in both hot 
and cold water, in both hot and cold saline solution (10 per cent. 



86 ANALYSIS OF URINE. 

NaCl), is precipitated with strong solutions of sodium chloride 
and magnesium sulphate ; also by saturated solution of Am 2 S0 4 ; 
is precipitated by nitric acid in the cold ; not soluble on heating, 
or only slightly so ; it is precipitated by copper sulphate. 

Hetero-albumose, insoluble in hot and cold water, is precipi- 
tated by dialysis from saline solutions ; soluble in both hot and 
cold solutions of sodium chloride of 10-per-cent. strength, — 
i.e., is partly precipitated, but not coagulated, on heating to 
65° C. ; is precipitated by saturation with sodium chloride or 
magnesium sulphate ; also with saturated ammonium sulphate ; 
and is precipitated b} 7 nitric acid in the cold, the precipitate 
being dissolved with heat and re-appearing on cooling. 

Deutero-albumose is soluble in hot and cold water; soluble 
in hot and cold solutions of sodium chloride of 10-per-cent. 
strength ; is not precipitated by saturation with sodium chloride 
or magnesium sulphate, but is precipitated by saturation with 
ammonium sulphate ; while with nitric acid it is only precipi- 
tated in the presence of excess of salt. 

Peptonuria. 

Peptones are best known as the final products of gastric and 
pancreatic digestion. They are also products of retrogressive 
changes in albuminoids and of the corpuscular elements of the 
blood, and as such assume importance in their clinical relations. 
It has just been stated that peptones are the final products 
of gastric and pancreatic digestion. If hydration were con- 
tinued a step farther, peptone would be split up into simpler 
substances, and would no longer constitute a proteid. Pep- 
tones are soluble in water, uncoagulable by heat, and are not 
precipitated by nitric acid, copper sulphate, ammonium sul- 
phate, potassium ferrocyanide, and a number of other pre- 
cipitants of proteids. The} 7 are precipitated b} 7 tannin, potassio- 
mercuric iodide, phosphomolybdic acid, phosphotungstic acid, 
and picric acid. 

Peptones are divisible into two forms : (a) Hemipeptone, 
which by further action of the pancreatic juice is split up into 
leucin and t} 7 rosm and such simpler products. (b) Antipeptone, 
which is not decomposed further by pancreatic juice. It, fur- 



ABNORMAL CONSTITUENTS OF URINE. 87 

thermore, does not yield tyrosin on treatment with sulphuric 
acid, and does not respond to Millon's reagent. 

Both forms of peptone are readily diffusible through animal 
membranes, albumoses being only slightly so, and albumin not 
so at all, under ordinary circumstances. The peptones are not 
precipitated by saturation with ammonium sulphate, in which 
respect they differ from albumoses. 

Clinical Significance. — Peptone is absent from normal urine, 
but has been described in the urine in connection with numerous 
pathological conditions. Since the recent publication of Kulm 
and Chittenden's work on proteoses and peptones, it has been 
made evident that many of the cases formerly described as pep- 
tonuria were, in reality, albumosuria, the real proteid present 
being deutero-albumose, and, therefore, much of our supposed 
knowledge of peptonuria needs revision. 

Peptonuria has been frequentty described as associated with 
the following conditions : In phosphorus poisoning, in suppura- 
tive diseases, in croupous pneumonia, acute rheumatism, typhoid 
fever, typhus, small-pox, scarlet fever, mumps, tuberculosis, ery- 
sipelas, empyema, cancer of the viscera (notably of the liver and 
intestines), catarrhal jaundice, apoplexy, etc. The local — some- 
times termed the pyogenic — causes seem to be connected with 
resorption of exudations so situated as to favor the products of 
disorganization — the peptone constituent of leucocytes — being 
absorbed into the circulation, from whence it is eliminated by 
the kidneys. This form of peptonuria is met with in the declin- 
ing stages of pneumonia, in purulent pleuritis, suppurating 
tuberculosis, chronic bronchial catarrh, psoas abscess, purulent 
meningitis, and acute articular rheumatism. 

In acute inflammatory affections the appearance of pep- 
tonuria may be taken as an evidence that suppurative changes 
have been established, other known causes of peptonuria being- 
excluded. Jaksch insists that, as a means of distinguishing 
between tubercular and epidemic cerebro-spinal meningitis, 
peptonuria is of crucial significance, being absent in the former 
and characteristic of the latter. In this connection, however, 
ulcerative changes in the lungs must be excluded to render this 
sign trustworthy. 



88 ANALYSIS OF URINE. 

In like manner, peptonuria appearing as is usual in septi- 
caemia may serve to distinguish it from latent disseminated 
sarcoma when, as often happens, the clinical symptoms are very 
similar. In short, Maixner has declared it the law that peptone 
is alwa} T s present in the urine when pus is forming in the 
organism. 

In addition to the pyogenic causes of peptonuria, extensive 
destruction of the corpuscular elements of the blood seems to 
constitute a prominent cause, and hence the frequent appearance 
of peptonuria in acute infectious diseases and toxic conditions 
already enumerated. 

Peptonuria also arises from a few additional causes. It is 
almost invariably associated with cancer of the liver, and this 
fact has led Pecancowski to the conclusion that the liver in 
health is concerned in the conversion of peptone into albumin. 
Maixner has shown that in ulceration of the intestines the 
peptic products of the stomach pass directly into the blood 
through the ulcerated surfaces, and give rise to peptonuria. 
Then, again, we have puerperal peptonuria, Fischel having 
shown that peptone is a normal constituent of the urine in the 
puerperal condition. Final^, when injected into the blood, 
peptone quickly appears in the urine. 

Detection. — Peptone may be recognized b}" the following- 
method : Saturate the urine (slightly acidified first with acetic 
acid) with ammonium sulphate, and filter out any precipitate 
formed which may consist of albumin, globulin, proto-albumose, 
hetero-albumose, or deutero-albumose. Any proteid remaining 
may be precipitated by potassio-mercuric iodide or picric acid, 
and can only be peptone. This is, in fact, the only certain 
method of identification of peptone. 

Differentiation. — Since peptone and deutero-albumose so 
closely resemble each other in reactions, it is well to be able 
to distinguish them, more particularly since the frequency with 
which they have been confounded has undoubtedly led to 
numerous clinical errors. Halliburton contrasts them as fol- 
lows : — 



ABNORMAL CONSTITUENTS OF URINE. 89 



Peptone. 
1. Gives no precipitate with nitric 
acid. 



2. Is not precipitated by saturation 
with ammonium sulphate. 



Deutero-albumose. 

1. Gives no precipitate with nitric 
acid unless a considerable amount of 
salt be added. This precipitate dis- 
appears on heating and re-appears on 
cooling. 

2. Is precipitated by saturation with 
ammonium sulphate. 

In all other respects these two substances, as far as known, 
behave similarly. 

Recent researches by Kuhn 1 have shown that, in order to 
effect complete separation of the albumoses from peptones, the 
mixture containing these substances should be saturated whilst 
boiling with ammonium sulphate. Furthermore, a single satu- 
ration with ammonium sulphate should not be depended upon 
to remove all the deutero-albumose, but saturation should be 
repeated till precipitation no longer occurs. 

Globulinuria. 

Globulin is insoluble in water, but dissolves in dilute neutral 
salt solutions. From these solutions it is precipitated by suf- 
ficient dilution with water, and on heating it coagulates. Globu- 
lin dissolves in water on the addition of very little acid or alkali, 
and on neutralizing the solvent it re-precipitates. Solutions of 
globulin in a minimum amount of alkali are precipitated by 
carbon dioxide, but the precipitate ma}^ be dissolved by excess 
of the precipitant. The neutral solutions of globulin containing 
salts are precipitated on saturation with sodium chloride and 
magnesium sulphate at normal temperatures. Normal urine is 
free from globulin, but this proteid appears in the urine in a 
number of pathological conditions. 

Clinical Significance. — Globulinuria is nearly always asso- 
ciated with albuminuria, and, indeed, globulin may greatly ex- 
ceed the quantity of albumin present in some cases, although the 
proportion of globulin in the blood is only as 1 to albumin 1.5. 
Globulin is, however, a more diffusible form of proteid than 
albumin, which may account for its proportional excess in the 

1 W. Kuhn, Erfahrungen iiber Albumosen und Peptone, I. Reinigung der 
Peptone von Albumosen. Separatabdruck aus der Zeitschrift f. Biologie, 1893. 



90 ANALYSIS OF URINE. 

urine at times. From the fact already stated, that globulin is 
nearly always associated with albumin in the urine, its clinical 
significance is nearly identical with that of albuminuria. In a 
few cases, however, its presence in the urine seems to imply a 
special significance. Thus, globulin is noted in unusual quanti- 
ties in the urine in catarrhal inflammations of the bladder, in 
acute nephritis, and especially in amyloid degeneration of the 
kidneys. The same is said to be the case in albuminuria asso- 
ciated with digestive disorders. On the other hand, in chronic 
B right's disease globulin is said to be present in very small 
amount, or even at times absent. 

Detection. — 1. Exactly neutralize the urine, filter, and treat 
with magnesium sulphate in substance until it be completely satu- 
rated at an ordinary temperature, or with a saturated solution of 
ammonium sulphate. In both cases a white precipitate is formed 
if globulin be present. In using ammonium sulphate with urines 
rich in urates, precipitation of ammonium urate may appear. 
These, however, do not immediately appear, but only after some 
time, and they may thus be distinguished from the globulin pre- 
cipitate. 

In detecting serum-albumin in the same urine, heat the fil- 
trate after precipitation of the globulin to boiling, after the 
addition of a few drops of acetic acid. 

2. Globulin falls out of solution when the urine is diluted 
until the specific gravity is about 1002, and upon the above fact 
Roberts suggested the following simple test: Fill a wineglass 
or test-tube with water and let fall into it several drops of albu- 
minous urine. If globulin be present in any quantit}^, each drop 
as it falls is followed by a milky streak, and when a number of 
drops have been added the water assumes a milky opalescence 
throughout. The addition of acetic acid causes the opalescence 
to disappear. 

Determination. — The separate determination of globulin and 
albumin may be accomplished by carefully neutralizing the urine 
and precipitating with magnesium sulphate added to saturation, 
or by simply adding an equal volume of saturated solution 
(neutral) of ammonium sulphate. The precipitated globulin is 
thoroughly washed with saturated magnesium sulphate, or half 



ABNORMAL CONSTITUENTS OF URINE. 91 

saturated ammonium-sulphate solution, dried at 110° C, boiled 
with water, extracted with alcohol and ether ; then dried, weighed, 
and ashed; then weighed again, and the weight is the amount of 

globulin. 

Differential Testing. 

Serum-albumin, serum-globulin, hetero-proteose, deutero-pro- 
teose, and peptone may all be present in the urine simultaneously. 
This is very unusual, but in doubtful cases the only certain 
method is to test for each one in the list. The best method of 
doing this is that proposed by Halliburton, as follows : — 

1. If the urine give no precipitate on boiling after acidulation, 
albumin and globulin are absent. If a precipitate occur, albu- 
min or globulin, or both, are present. 

2. If the urine after neutralization give no precipitate on 
saturation with magnesium sulphate, globulin and hetero-proteose 
are absent. If such precipitate occur, one or the other is present. 

3. If the urine be saturated with ammonium sulphate and 
filtered, and the filtrate gives no xanthoproteic or biuret reaction 
(a large excess of potash must alwaj's be added), peptone is 
absent. 

4. If the urine give no precipitate on boiling after acidu- 
lation, no precipitate with nitric acid, and no precipitate on 
adding ammonium sulphate to saturation, peptone can be the 
only proteid present. Confirm this by the biuret reaction. 

5. If all proteids are present, they may be separated as fol- 
lows : — 

Saturate the urine (faintly acidified with acetic acid) with 
ammonium sulphate. A precipitate is produced. Filter. 



(&) Filtrate. 
Contains peptone. 



(a) Precipitate. 

Contains albumin, globulin, hetero- 
and deutero- proteose. 

Collect the precipitate on a filter, wash it with saturated solu- 
tion of ammonium sulphate, and redissolve it by adding a small 
quantity of water. To this solution add ten times its volume of 
alcohol ; a precipitate is formed ; collect this, and let it stand in 
absolute alcohol for from seven to fourteen (biys. Then filter off 
the alcohol, dry the precipitate at 40° C, extract with water and 
filter. An insoluble residue is left. 



92 ANALYSIS OF URINE. 



This contains the proteoses in solu- 
tion. 



(a) Residue. (&) Extract. 

This consists of albumin and globu 
lin coagulated by alcohol. 

Hetero-proteose is precipitated by heating the solution to 
65° C, or by saturating a portion of the extract with magnesium 
sulphate. Deutero-proteose remains in solution. 

Take another portion of the urine, neutralize it, and saturate 
with magnesium sulphate. A precipitate is produced. Filter. 



(a) Precipitate. 
This consists of globulin and hetero- 
proteose, which may be separated by 
the prolonged use of alcohol, as above. 



(&) Filtrate. 
This contains albumin, deutero-pro- 
teose, and peptone. Add alcohol, as 
above ; albumin is rendered, in seven 
days, insoluble in water. The deutero- 
proteose and peptone are soluble, and 
may then be separated by ammonium 
sulphate. 

The reactions of the several proteids in the urine already con- 
sidered may be seen at a glance in the following table, after 
Halliburton. (See next page.) 

HEMOGLOBINURIA. 

Haemoglobin, the red pigment of the blood, is a somewhat 
remarkable compound in that it contains iron, is intimately asso- 
ciated with a proteid, and gives the proteid reaction ; it is hence 
non-diffusible, but } T et is crystalline. It exists in the blood in 
two conditions, — in arterial blood it is termed oxyhemoglobin, 
being charged with oxygen ; in venous blood it is deox} T genated 
or reduced haemoglobin. Haemoglobin belongs to the group of 
blood-proteids, which 3'ields splitting products and small amounts 
of volatile fatty acids with about 96 per cent, albumin and about 
4 per cent, haemochromogen, containing iron, which, in the pres- 
ence of ox} T gen, is readily oxidized into haematin. Haemoglobin 
prepared from different kinds of blood has not always the same 
constitution, indicating the probable presence of different haemo- 
globins. This is further shown b} r the facts that different kinds of 
blood also differ in solubility and crystalline form, and possess a 
varying quantity of water of crystallization. 

The Clinical Significance. — The blood-pigment, haemoglobin, 
sometimes appears in the urine without the appearance of any 



ABNORMAL CONSTITUENTS OF URINE. 



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94 ANALYSIS OF URINE. 

corpuscles associated therewith, as was first shown by Pavy. 
This is always the result of the destruction of the blood-cor- 
puscles in the circulating stream. The haemoglobin thus liberated 
is thrown out by the kidneys and appears in the urine. This may 
be produced by injection into the circulation of substances which 
act as solvents of the corpuscles, such as glycerin, solutions of 
the bile-salts, distilled water, and the injection of the blood of 
one animal into another. Similar results follow in cases of 
poisoning with arseniuretted hydrogen ; hydrochloric, sulphuric, 
carbolic, and pyrogallic acids ; phosphorus, and potassium chlo- 
rate. In certain diseases, notably pyaemia, typhus, scurvy, fat- 
embolism, in some cases of jaundice, and after extensive burns, 
hemoglobinuria often results. The most interesting and marked 
pathological condition in which haemoglobin appears in the 
urine is the disease known as paroxysmal hemoglobinuria, which 
will form the subject of special consideration in a subsequent 
section of this work. 

Detection. — 1. Solutions of haemoglobin ma} 7 be determined 
b} r spectroscopic examination with great precision. The}'- 
strongly absorb the ra3 T s lying between G and D. In a proper 
dilution the solution shows a spectrum with one broad, not 
sharply-defined band between D and F. This band does not lie 
in the middle, between D and E, but is toward the red end of 
the spectrum, a little over the line D. 

2. Guaiacum Teat. — Mix in a test-tube equal volumes of 
tincture of guaiacum and old turpentine which has become 
strongly ozonized \>y the action of air under the influence of 
light. To this mixture, which must not have any blue color, add 
the urine to be tested. In the presence of haemoglobin, first a 
bluish green, and then a beautiful blue ring appears where the 
two liquids meet. On shaking, the mixture becomes blue. Nor- 
mal urine, and albuminous urine, do not give this reaction. 
Urine containing pus also gives a blue color with the above re- 
agents ; but in this case the tincture of guaiacum alone, without 
the turpentine, is colored blue by the urine. The blue color 
produced hy pus differs from that produced by haemoglobin by 
disappearing on heating the urine to the boiling-point. 

Urines, if alkaline from decomposition, must first be made 



ABNORMAL CONSTITUENTS OF URINE. 95 

faintly acid before applying this test. The turpentine should be 
kept exposed to the light, while the guaiacum should be kept in 
a dark-glass bottle. 

3. Helle?'^ Test. — If a neutral or faintly-acid urine containing 
haemoglobin be heated to boiling, there is obtained a mottled 
precipitate of albumin and lisematin. If caustic sodium be added 
to the boiling-hot test, the liquid becomes clear and turns green 
when examined in thin laj^ers, and a red precipitate, appearing 
green by reflected light, re-forms, which consists of earthy phos- 
phates and haematin. 

FlBRINURIA. 

Fibrin is a whitish, stringy solid when fresh, but upon 
drying it becomes of a grayish color. It is feebly soluble in 
6-per-cent. solutions of potassium nitrate, in 5- to 15-per-cent. 
solutions of sodium chloride, in 5- to 10-per-cent. solutions of 
magnesium sulphate ; and in solutions of other neutral salts, 
such as sodium sulphate and ammonium sulphate, most readily 
at a temperature of 40° C. It is insoluble in water, alcohol, and 
ether. It swells up in weak hydrochloric-acid solutions (0.2 per 
cent.), and also in sodium or potassium hydrate solutions (0.2 
per cent.), into a gelatinous mass. Stronger acids slowly dis- 
solve fibrin with the formation of acid albumin (syntonin) and 
albumoses. 

Digestive ferments act readity on fibrin. Thus, pepsin in an 
acid solution and trypsin (from the pancreas) in an alkaline 
solution cause, in the first place, a splitting up of the fibrin into 
two globulins, one coagulating at 56° C, the other at 75° C. 
Then the formation of albumoses and peptones follows. 

Fibrin separates on the so-called spontaneous coagulation of 
the blood, lymph, and transudations. 

Clinical Significance. — Fibrin may appear in the urine from 
various causes, either in solution or in coagulated flakes or masses. 
In the urine fibrin constitutes the basis of the so-called coagu- 
lable urine, which, upon standing some time, forms the fibrinous 
coagula. The quantity of fibrin present in the urine determines 
the extent of coagulation ; sometimes only a sticky sediment 
forms at the bottom of the vessel; more rarel} r the coagulation 



96 ANALYSIS OF URINE. 

involves the whole volume of urine, converting it into a sticky, 
gelatinous mass. This form of fibrinuria is seldom met with in 
the United States, but it occurs frequently as a special form of 
disease in Brazil and the Isle of France. 

Fibrinuria, as it occurs with us, uniformly indicates that an 
exudation of fibrinous fluid — blood-plasma — has gained access 
to some part of the urinary tract. In most cases it comes from 
the kidneys, although it may result from intense inflammation 
of the lower urinary passages. It is often associated with 
haemorrhages into the urinary tract, and it has been observed 
frequently in cases of villous tumors of the bladder. 

It is important to distinguish between fibrinuria and those 
cases of pyuria in which large quantities of pus are present in 
highl3 r -alkaline urine. In cj^stitis of long standing the ammo- 
nium carbonate resulting from bacterial decomposition of the 
urine may form with pus a gelatinous, sticky mass, which may 
be readily mistaken for fibrin coagulum. Such a urine, however, 
is thinned by the addition of water, and, moreover, if treated 
with acetic acid, a white precipitate falls, consisting of alkaline 
albuminate. 

Detection. — The coagulum should be separated by filtration 
and washed with water, when it will show the following: char- 
acters : — 

1. It does not dissolve in water, but it swells up in 1-per-cent. 
solutions of hydrochloric acid, and is onty dissolved when pepsin 
is added. 

2. Separate the coagula from the urine by filtration through 
fine muslin, and wash with cold water. Treat a part of the 
mass with dilute solution of sodium hydroxide; if insoluble 
upon long standing, the indication is that it is fibrin, since albu- 
minous bodies dissolve in sodium-hydroxide solutions. Treat 
another portion of the mass with a 1-per-cent. solution of sodium 
carbonate. Fibrin dissolves completely in this solution if 
warmed gently several hours on a water-bath. This solution is 
then filtered and treated with Millon's reagent, when a deep-red 
color is produced. 



ABNORMAL CONSTITUENTS OF URINE. 97 

MUCJNURJA. 

Mucin, being the essential constituent of mucus, is, there- 
fore, present in all urines, normal and abnormal; though in the 
urine of health the amount present is so minute as ordinarily to 
escape observation and elude all but the most delicate testing. 
Mucin is a proteid closely allied to the albumins, and may be 
made to yield albuminates and albumoses by boiling with dilute 
mineral acids. It is mucin that gives to the saliva, bile, and 
synovial fluids their peculiar, ropy consistency. The general 
features of the formation of mucin by mucous cells, and espe- 
cially the behavior of the mucous granules ill relation to the 
secretory activity of the submaxillary gland, 1 strongly indicate 
that mucin is derived from the true albumins; and, moreover, 
it yields many of the characteristics of proteids (Millon's and 
xanthoproteic reactions), and, as already noted, with mineral 
acids albuminates may be obtained. Our knowledge of mucin, 
however, as yet may be said to be in a somewhat transitional 
condition, since recent investigations render it probable that 
mucins derived from different sources are distinct substances, as 
are the different forms of albumins. Notwithstanding these 
facts, all mucins, from whatever source derived, possess certain 
features in common, — viz., they are non-coagulable by heat, 
soluble in alkalies and strong mineral acids. They are precipi- 
tated by strong alcohol and organic acids, as well as by dilute 
mineral acids. The presence of mucin in the urine, when in 
excess, constitutes one of the most frequent sources of error 
in searching for small quantities of albumin, as already shown. 
(See tests for albumin.) 

Clinical Significance. — Mucin occurs in the urine in in- 
creased quantity in catarrhal inflammations of the urinary pass- 
ages, more especially of the bladder. In cystitis and pyelitis 
the mucin in the urine is often very excessive, forming ropy, 
tenacious strings, and even sometimes settling in a jelly-like 
mass. Irritation of the urinary passages without inflamma- 
tion or the formation of pus often causes a notable increase o( 
mucin in the urine. An increase is also common in various 



1 Langley, Journal of Physiology, vol. \, L889, p. 488, 

7 



98 ANALYSIS OF URINE. 

febrile conditions, as pneumonia, pleuritis, typhoid fever, inter- 
mittent fever, pulmonary and intestinal catarrhs. It is of special 
interest to note, in this connection, as Reissner has pointed out, 
that in the beginning of the febrile state mucin often appears 
in the urine. A few days later albumin is often present ; the 
latter usually disappears, after a longer or shorter time, while 
the mucin continues some days longer. Cases may be considered 
rare, according to Reissner, in which notable quantities of mucin 
in the urine persist for many days, under febrile conditions, with- 
out the appearance of albumin also. These facts should espe- 
cially be borne in mind in scarlatina and the acute infectious 
fevers most often followed b} T nephritis, since, under such circum- 
stances, the presence of mucin in the urine in marked quantities 
maj r serve to put the physician upon his guard against the 
approach of serious complications involving the kidneys. 

Detection. — First dilute the urine with water, partly to pre- 
vent precipitation of uric acid on the subsequent addition of 
acid, and more especially to diminish the solubility of mucin by 
the sodium chloride of the urine. Next add an excess of acetic 
acid. The precipitate formed is mucin, and may be purified by 
dissolving in water, by the addition of a little alkali, and re- 
precipitating with acetic acid. 

To distinguish between mucin and albumin in urine which 
gives proteid reactions, add to a column of urine three inches in 
depth in an ordinary test-tube about 1 drachm of potassium- 
ferroc3 r anide solution (1 in 20) ; after thorough mingling of 
these, add 10 to 15 drops of acetic acid. If precipitation occur, 
albumin, and not mucin, is present. Next test as described 
above for mucin, and in presence of precipitation mucin, and 
not albumin, is present. 



SECTION IV. 

CARBOHYDRATES. 

The carbohydrates resemble one another in their chemical 
composition, in all containing 6 atoms of carbon, or a multiple 
thereof. They also resemble one another in their chemical char- 
acters, being neutral in reaction, not prone to enter into combi- 
nations, and, with the exception of inosite, they all possess' a 
strong rotatory power over polarized light. 

A number of carbohydrates are met with in the urine, — viz., 
glucose, levulose, lactose, inosite, etc., — but the chief clinical 
interest with regard to this class of compounds at present 
belongs to grape-sugar. 

Glycosuria. 

Grape-sugar, or dextrose, in its pure form crystallizes in 
rhombic tablets, is soluble in its own weight of water, and gives 
a dextro-rotatory power over polarized light of = -j- 56° (Hoppe- 
Seyler). Its solutions become brown when boiled with liquor 
potassae, but with picric acid a deep mahogany red. In alkaline 
solutions it reduces salts of silver, bismuth, mercury, and cop- 
per ; with the first three the metal is precipitated, cupric being- 
reduced to cuprous compounds, with separation of cuprous 
oxide. Faintly-alkaline solutions of grape-sugar, colored blue 
by indigo, when boiled exhibit a beautiful color reaction, begin- 
ning with violet and ending in yellow. With solutions of sodium 
acetate it reduces phenylhyclrazin hydrochloride to phenylglu- 
cosazone, forming highly characteristic and beautiful, golden- 
yellow, acicular crystals. 

Grape-sugar exists in minute quantity in normal blood, 
varying chiefly with the functional activity of the liver. In 
some abnormal states of the S3 T stem the amount of sugar in the 
blood becomes markedly increased, reaching its maximum — 
about y 1 ^ per cent. — in the more pronounced diabetic conditions. 

The ardently-disputed question if sugar be present in normal 
urine seems to have been conclusively settled in the affirmative 

(99) 



100 ANALYSIS OF URINE. 

through the researches of Wedenski (see Section II), although 
this is by no means universally conceded. Clinically speaking, 
this question is one of minor importance, since, if sugar be 
present in normal urine, it exists in such exceedingly minute 
quantity that it is unrecognizable by the ordinary methods of 
testing, and such quantities give rise to no marked clinical 
symptoms. 

Clinical Significance. — Glycosuria may appear as a temporary 
condition in the course of a number of diseases, as cholera, 
intermittent fever, scarlatina, gout, cerebro-spinal meningitis, 
diseases of the lungs, liver, and the brain, especially if involving 
the fourth ventricle or vicinity. The administration of certain 
drugs and toxic substances causes the appearance of sugar in the 
urine, such as curare, carbonic oxide, amyl nitrite, methyl- 
delphinin, morphine, chloral, hydrocyanic acid, sulphuric acid, 
mercury, alcohol, strychnine, salicylic acid, turpentine, uranium 
nitrite, benzol, acetone, and phloridzin. Recent investigations 
have shown, however, in some of these cases, that the toxic 
agent merely causes the appearance of reducing agents 1 in the 
urine other than sugar. 

Glycosuria maybe produced experimentally by A r arious lesions, 
as follows : By puncture of the floor of the fourth ventricle of the 
brain ; injury to the vermiform process of the cerebellum; sec- 
tion of the spinal cord in different locations ; destruction of 
various sympathetic ganglia; section of the splanchnic nerves; 
irritation of the vagus ; section and stimulation of the central 
end of large motor nerves, as the sciatic ; and bj^ total extir- 
pation of the pancreas in dogs. In addition to these, experi- 
mental glycosuria may be induced by measures which cause 
increased determination of blood to the liver, as by tying the 
accessory branch of the portal vein in animals, irritation of the 
liver by needle-punctures, compression of the aorta, etc. 

Glycosuria in mild form imy occur from disorders of the 
stomach, and, in some cases, the overingestion of starchy and 
saccharine foods will cause the appearance of sugar in the urine. 

Glycosuria, however, of pronounced and persistent form 

1 Usually glycuronic acid. 



ABNORMAL CONSTITUENTS OP URINE. 101 

belongs to the province of diabetes mellitus, and may always be 
regarded as symptomatic of grave defects either in the brain, 
liver, or pancreas. In young subjects the disease is almost uni- 
formly progressive toward a fatal termination in from a few 
months to four or five years, notably so with patients under 20 
years of age. During the middle period of life the disease is 
often less severe and less fatal. After the age of 50 it is often 
mild and amenable to treatment. Persistent glycosuria is the 
most constant and certain of all the symptoms of diabetes 
mellitus, being, in fact, sometimes the only symptom of the 
disease, and herein lies its great value for diagnostic pur- 
poses. It,- therefore, becomes highly essential to be able to 
readily detect the presence of sugar in the urine, since diag- 
nostic data of the most positive nature often hinges upon this 
point alone. 

Detection of Sugar in the Urine. — The most popular method 
of searching for sugar in the urine has, heretofore, been by 
means of the copper tests. These all depend upon the fact, 
already noted, that in strongly-alkaline solutions grape-sugar 
reduces cupric oxide to lower grades of oxidation. 

1. Trommer's Test. — This test may be conveniently per- 
formed as follows : About 1 drachm of urine, in an ordinary 
test-tube, is first treated with sufficient cupric-sulphate solution 
to render the urine a light-green color ; then an equal volume of 
liquor potassae is added. At first a blue precipitate of lvydrated 
cupric protoxide results, which dissolves upon shaking the tube, 
forming a beautiful, clear, blue solution. If allowed to stand 
half an hour or so, reduction gradually takes place, especially if 
much sugar be present, resulting in precipitation of yellow or 
yellowish-red suboxide of copper. If, instead of standing half 
an hour, gentle heat be applied, this test becomes more delicate, 
and reduction, moreover, occurs at once. 

This test is open to two objections : (a) If it be not sub- 
mitted to boiling it is not very sensitive, only detecting sugar 
when present in considerable quantitj'. (b) If boiled especiallj' 
long the test is rendered oversensitive, so that reaction may 
occur with substances in the urine other than sugar. The power 
of reducing cupric oxide in alkaline solution is possessed, to 



102 ANALYSIS OF URINE. 

a feeble degree, by a number of substances 1 in both normal and 
abnormal urine, and in Trommer's test the quanta of urine 
submitted to the copper solution is relatively large, which 
greatly increases the chances of reduction by non-saccharine 
agents. 

2. Fehling^s Solution. — This solution is prepared according 
to the original standard formula, as follows : 34,639 grammes 
pure ciystallized cupric sulphate; solution of sodium hydroxid 
(specific gravity, 1.12), about 500 cubic centimetres; chemically 
pure neutral sodium tartrate, 173 grammes. Prepare by dis- 
solving the copper sulphate in 100 cubic centimetres of distilled 
water; next dissolve the neutral sodium tartrate in the caustic- 
sodium solution, and add the copper solution, little by little; 
finally, with distilled water bring the volume of the whole to 
1000 cubic centimetres (1 litre). 

Fehling's test may be applied as follows: Fill an ordinary 
test-tube to the depth of about an inch with the test solution, 
and raise to the boiling-point over a spirit-lamp. If upon boiling 
the solution remain clear blue, 3 or 4 drops of the suspected 
urine should be added, at the same time continuing the boiling; 
and if much sugar be present after a short interval, the solution 
suddenly assumes a dense, opaque, yellow color, and shortly 
after a yellowish-red sediment falls to the bottom of the test- 
tube. If no such reaction occur, the addition of urine ma}' be 
continued until its volume equals, but must not exceed, the 
volume of the test; then, if no 3 T ellowish precipitate appear 
upon boiling, the urine may be considered free from sugar. 

The chief objection to Fehling's solution is its well-known 
tendency to decompose upon keeping, so that it must be freshly 
prepared in order to be depended upon. Various methods have 
been proposed for the purpose of rendering this test stable. 
Thus, Dr. Pav}' suggested having the solid ingredients com- 
pressed into pellets, the cupric salt and sodium tartrate being in 
separate pellets. In the author's experience these pellets are 
even more unstable than the liquid form of the test. The defect 
in Fehling's solution depends upon its contained sodium tartrate, 

1 Chiefly uric acid, creatin, creatinin, hippuric acid, hypoxanthin, tannin, 
carbolic acid, alkaloids, and glycuronic acid. 



ABNORMAL CONSTITUENTS OF URTNE. 103 

— a very unstable salt ; and so long as this be retained a portion 
thereof will be converted into racemic acid, which reduces 
cupric oxide and corrupts the test. 

3. Haines 1 s Test. — The best form of copper test for sugar, 
qualitatively, is that devised by Prof. Walter S. Haines, of 
Chicago. The original formula for this test is as follows : Pure 
cupric sulphate, 30 grains; pure glycerin, 4 drachms; caustic 
potash (in sticks), 3 drachms; distilled water, to 6 ounces. 
The solution is prepared b} r dissolving the cupric sulphate and 
glycerin in part of the water and the caustic potash in the 
remainder. Mix the two solutions. 

For purposes of greater convenience, Professor Haines has 
recently simplified this formula, as follows : Take pure copper 
sulphate, 30 grains ; distilled water, ^ ounce ; make a perfect 
solution, and add pure glycerin, \ ounce ; mix thoroughly, and 
add 5 ounces of liquor potassse. 

In testing with this solution, take about 1 drachm and 
gently boil it in an ordinary test-tube. Next add from 6 to 8 
drops — not more — of the suspected urine, and again gently boil. 
If sugar be present, a copious }'ellow or yellowish-red precipitate 
is thrown down. If no such precipitate appear, sugar is absent. 
This test is stable, and, though kept on hand indefinitely, it m&y 
always be depended upon to be in order for testing. 

With regard to the copper tests in general : It has often been 
stated that if albumin be present in the urine it must first be 
removed, as it interferes with the reduction of the cupric oxide. 
In the author's experience, this rule may ordinarily be disre- 
garded unless the albumin be very excessive. With regard to 
boiling, it is important to bear in mind that, if this be continued 
too long, slight reduction is apt to occur with the urine, even 
when free from sugar, as evidenced by a slight greenish (not 
yellow) opacity; about half a minute should constitute the usual 
limit of boiling. It should also be borne in mind that strongly 
alkaline solutions are apt to precipitate the earthy phosphates of 
calcium and magnesium of normal urine in the form of a grayish 
cloud, which should not be mistaken for sugar. 

4. The Fermentation Test. — This test depends upon the fact 
that grape-sugar is decomposed in the fermentation set up by 



104 ANALYSTS OF URINE. 

yeast, yielding alcohol, carbon dioxide, succinic acid, and a 
number of other products, with resulting decrease in the specific 
gravity of the urine. The following is the method emploj-ed : 
Fill an ordinary test-tube half full of mercury and the remain- 
ing half with the urine to be tested, and introduce into the 
urine a small piece of German yeast. Next close the mouth of 
the test-tube with the thumb and invert over a small vessel of 
mercury, and set aside in a warm room for several hours. If 
sugar be present fermentation proceeds at once, liberating the 
carbonic-acid gas which collects in the upper end of the tube, 
displacing the urine and mercury more or less, according to the 
quantity of sugar present. One precaution should be observed. 
Some specimens of yeast spontaneously evolve gas, and it is, 
therefore, best to perforin a parallel experiment with }-east 
mixed with water, so that the spontaneously evolved gas ma}^ 
be estimated. 

This test will detect sugar, if present in considerable quan- 
tity, — 1 per cent, and over. — but the capacit3 T of the urine itself 
for absorbing carbonic gas renders this test uncertain in detect- 
ing smaller quantities of sugar. The more serious disadvantage 
of this test for practical work is the fact that it requires several 
hours to complete the anatysis. 

5. The Bismuth Test. — Sugar possesses the power of re- 
ducing bismuth salts with resulting black precipitate, and upon 
this fact Bottger first suggested the following simple test : First 
add to the urine an equal volume of liquor potassse and then a 
little basic nitrate of bismuth. Gently boil the whole, and if 
sugar be present the test turns gray or black, according to the 
amount of sugar present. 

Traces of sulphur, which are often present in the urine, cause 
the same reaction with this test as does sugar. For the above 
reason, albumin, if present, must be removed before appl} T ing 
this test. 

In order to eliminate the errors due to the presence of sul- 
phur, Brucke suggested the following improvement of the 
bismuth test : Fill a test-tube half full of the suspected urine 
and another with a similar volume of water, and stand them side 
b}' side. To the one containing water add lrydrochloric acid 



PLATE IV. 




Crystals of Phenylglucosazone. 
(After v. Jaksch.) 



ABNORMAL CONSTITUENTS OF URINE. 105 

until a drop of Frohn's reagent 1 no longer produces a cloudiness. 
By this means an approximate estimation may be made of the 
quantity of hydrochloric acid which should be added to the 
urine. Acidify the urine with such quantit}' of hydrochloric 
acid, add the reagent, and filter. The filtrate, which should now 
remain clear upon adding hydrochloric acid, or the reagent, 
should be boiled with an excess of potassium or sodium hydrate, 
as in Bottger's method ; and, if a gray or black color result, sugar 
is present. 

6. Fhenylhydrazin Teat. — This test, suggested by Fischer, 
depends upon the power, possessed by phenylhydrazin hydro- 
chloride, of forming with grape-sugar a highly-characteristic 
crystalline compound, termed phenylglucosazone. The best 
method of applying this test is as follows : To 25 cubic centi- 
metres of suspected urine add 1 gramme of phenylhydrazin 
hydrochloride, 0.75 gramme of sodium acetate, and 10 cubic 
centimetres of distilled water in a capsule. The capsule should 
be placed in a water-bath and warmed at least an hour, then re- 
moved and allowed to cool; and if sugar be present even in 
minute quantit}', there forms a yellowish deposit, which may ap- 
pear amorphous to the naked e}^, but which, when examined 
under the microscope, is seen to contain fine, bright-yellow, 
needle-like crystals, either single or in stars, — phenylgluco- 
sazo?ie, — which melt at 204° C. (Plate IY). The presence of small 
or large yellow scales or powerfully refracting brown spherules 
must not be taken for evidences of sugar, as only the bright- 
yellow, needle-like crystals are conclusive. 2 

If the mixture be left in the water-bath for a shorter time 
than an hour, a crystalline glvcuronic-acid compound is formed 
(melting-point, 150° C), which is likely to be mistaken for 
phenylglucosazone. For the same reason the method of boiling 
the reagents with the urine in a test-tube for only half a minute 

1 Frohn's reagent is prepared by mixing 1.5 grammes of freshly-precipitated 
bismuth subnitrate with 20 grammes of water, heated to boiling ; then 7 
grammes of potassium iodide and 20 drops of hydrochloric acid are added. 

2 In manipulating the phenylhydrazin hydrochloride caution should be 
observed not to get it on the hands, as it often causes troublesome eczema of very 
acute grade. 



106 ANALYSIS OF URINE. 

and cooling, as has been recommended by some, is apt to be 
misleading. 

This test gives A r ery trust worth} 7 results with every variet3 r 
of morbid urine, and is therefore equally applicable whether 
albumin be present or not. It gives no reaction with uric 
acid, urates, creatin, creatinin, oxybutyric acid, urochloralic 
acid, uroxanthic acid, tannin, morphine, salicylic acid, or 
carbolic acid. 

A number of other tests have been proposed for the detection 
of sugar in the urine, among which may be mentioned : Boiling 
with sodium or potassium hydroxid (Moore), picric acid (John- 
son), acetate of lead and ammonia (Rubner), alpha-naphthol 
and thymol (Molisch), indigo carmine (Mulder), bichloride of 
tin (Maumene), chromic acid (Hunefeld), diazo-benzol-sulphonic 
acid (Penzoldt), and sulphuric acid (Range). None of the above 
tests possess special advantages over those already described, 
while, on the contrary, most of them are greatly inferior. 

In addition to these, tests for sugar are prepared in paper 
form, by charging chemicalty-inert filtering-paper with sodium 
carbonate and indigo carmine. The chief merit of these papers 
is their portability., since they are neither sensitive nor trust- 
worthy in detecting sugar in the urine. 

Testing for Sugar in the Urine. — In searching for sugar in 
the urine, a test should, if possible, be selected which is simple 
in application, reasonably trustworthy, and perfectly stable, so 
that it may be depended upon when required, in routine work. 
In these respects Haines's test is veiy satisfactory. 

Before submitting the urine to reagents always thorough^ 
cleanse all of the utensils to be employed in the analysis. In 
the use of the copper tests, always employ a minimal amount 
of urine at first, gradually increasing until reaction is obtained 
or the stated limit of urine be reached. This method greatty 
diminishes the chances of reduction by other substances in 
the urine than sugar, and, moreover, it gives a rough idea of 
the quantit} 7 of sugar when present. Thus, if Haines's test be 
selected, after gentl} 7 boiling a drachm of the solution, add 2 or 
3 drops of urine ; then wait a moment, to see if reduction occur, 
before adding more urine, meantime continuing the boiling ; if 



ABNORMAL CONSTITUENTS OF URINE. 107 

no reaction occur after a few seconds, add 2 or 3 more drops of 
urine, and so on until 8 drops be added, but no more. 

If Fehling's solution be employed, gently boil a drachm of 
the test and, if it remain clear, add but a few drops of the sus- 
pected urine; then pause for a moment, continuing the boiling, 
and, if no reaction occur, add a few more drops of urine, and so 
on. If no reaction occur, continue the addition of urine until 
the volume thereof equals that of the test solution, but not 
more. 

If any doubts arise as to the presence of sugar in the sus- 
pected urine, after the application of a routine test, an appeal 
should be made to one or more of the others described. For 
such purpose the phenylhydrazin test is desirable above all 
others, both because of its exceeding delicac}* and its property 
of reacting with few known substances in the urine other than 
grape-sugar. 

Determination of Sugar in the Urine. — Having detected the 
presence of sugar in the urine, it becomes all important to deter- 
mine its quantity in all cases, because (a) such knowledge fur- 
nishes the most precise evidence of the grade and severity of 
the diseased state upon which it depends ; (b) it furnishes the 
most solid basis upon which to construct the diagnosis ; (c) it 
gives the most trustworthy evidence as to the results of treat- 
ment. 

1. The Fermentation Method. — The best results are reached 
with this test after the method suggested by Roberts. 1 It has 
already been stated that grape-sugar is decomposed in the fer- 
mentation set up by 3 T east, yielding alcohol, carbon dioxide, and 
a number of other products, with resulting decrease in the spe- 
cific gravity of the urine. Each degree of specific gravity lost 
in fermentation corresponds to 1 grain of sugar per fluidounce. 
Thus, if before fermentation the specific gravity of the urine 
be 1.040, and after fermentation it be 1.020, it will have contained 
20 grains of sugar per ounce. The method advised b} T Roberts 
is as follows : About 4 ounces of saccharine urine are put into a 
12-ounce bottle, and a lump of German yeast is added to it. 

1 Edinburgh Monthly Journal, October, 1861. 



108 ANALYSIS OP URINE. 

The bottle is then corked with a nicked cork (which permits the 
escape of the carbonic acid) and set aside, in a warm place, to 
ferment. Beside this is placed a tightly-corked 4-ounce bottle, 
filled with the same urine, but without any contained yeast. In 
about twenty-four hours the fermentation will have ceased. The 
fermented urine is then decanted into a urine glass and its spe- 
cific gravity is taken ; at the same time, the density of the 
un fermented urine in the companion bottle is observed and the 
density lost ascertained. The degrees of densit} T lost represent 
the number of grains of sugar in each fluidounce of the urine 
tested. The percentage may be approximately ascertained by 
multiplying the number of degrees lost by 0.23. 

The chief objection to this method for clinical work is the 
fact that it requires from eighteen to twenty-four hours to com- 
plete the aual}'sis. 

The fermentation saccharometer recently devised by Einhorn 
collects and measures the carbonic-acid gas evolved in fermenta- 
tion, and from the volume of gas evolved the percentage of 
sugar is estimated. The urine itself absorbs carbonic-acid gas 
in quantity about equal to its own volume, and this gas the 
instrument takes no note of. The results obtained by these 
instruments are only approximative, and, in the author's experi- 
ence, much less accurate than those obtained by Roberts's 
method of differential density. 

2. Fehling's Test. — This is conducted by the titration method 
with Fehling's standard solution, the formula of which has 
already been given. The principle of the process depends 
upon the fact that, in the reduction of cupric oxide in solu- 
tions of definite strength by grape-sugar, the blue coloration 
disappears by the addition of a definite quality of the sugar. 
Thus, with Fehling's solution every 10 cubic centimetres cor- 
respond to 0.05 gramme of grape-sugar, — or 200 grains to 1 
grain of sugar. The test ma}' be conducted as follows : Measure 
off 10 cubic centimetres of Fehling's solution in a glass flask 
and dilute with 3 or 4 volumes of water. The urine to be ana- 
lyzed should be diluted to a known degree — ordinarily 1 to 10 — 
unless the quantity of sugar be very small, in which case 1 to 5 
is a better dilution. Next, raise the diluted Fehling's solution 



ABNORMAL CONSTITUENTS OF URINE. 109 

to the boiling-point, and, after having filled the burette with the 
diluted urine, add the latter in successive small amounts to the 
boiling Fehling's solution until the blue color has entirely dis- 
appeared. After each fresh addition from the burette, the mixt- 
ure should be gently boiled and then allowed to stand for a few 
seconds, so that the yellow suboxide of copper may subside and 
the observer may see whether the mixture contains any blue 
color. As soon as the blue color has disappeared the quantity 
of diluted urine employed may be read off, and since it takes 
just 0.05 gramme of sugar to remove the blue coloration in the 
10 cubic centimetres of copper solution, from this the percentage 
of sugar in the urine may be readily reckoned. Thus, if 10 cubic 
centimetres of the diluted urine were required, this would rep- 
resent 1.2 cubic centimetres of urine, which would contain 0.05 
gramme of sugar. The number of grammes of sugar contained 
in 100 cubic centimetres of urine would be obtained by propor- 
tions, thus : — 

1.2 100 100X0.05 , 1C 

= — .*. x = =4.16 

0.05 x 1.2 

The objection to Fehling's standard solution, already noted, 
— viz., its instabilit}', — greatly detracts from its practical utility. 
In addition to this, in quantitative testing its end reaction is de- 
fectum; so that some practice is necessary in order to determine 
the precise point of reduction. 

Dr. Pavy improved the end reaction of the copper test for 
quantitative work by the addition of ammonia to his formula. 
Unfortunately, however, he retained the sodic tartrate, which 
renders his solution equally unstable with Fehling's solution. 
Neither of these solutions will keep sufficiently long to make 
them available for practical use. 

It has recently been proposed to alter Fehling's solution by 
substituting 175 cubic centimetres of pure glycerin for the sodic 
tartrate and 130 grammes of potassium hydroxid for the sodium- 
l^drate solution. The author finds, however, that this renders 
the end reaction of Fehling's solution still more defective, since 
the cupric suboxid formed in presence of the potassium base is 
less dense than with sodium, and therefore is more bulky and 



110 ANALYSIS OF URINE. 

takes a longer time to settle; so that it is very difficult to find 
the precise point of reduction. Furthermore, a more serious 
consequence of this proposed alteration of Fehling's formula is 
the fact that in changing the alkaline base of the test from 
sodium to potassium it also changes the ratio of reduction of 
the cupric oxide b} T sugar; so that the proposed formula would, 
in testing, indicate considerably more sugar in the urine than is 
actually present. The ratio of reduction of cupric oxide by 
sugar varies with the form of alkaline base emploj'ed. Thus, 
with sodium hydroxid (as in Fehling's solution) the ratio 
is 1 grain of sugar to 6.92 grains of cupric sulphate ; while with 
potassium hydroxid it is 1 grain of sugar to 6.66 grains of 
cupric sulphate. Fehling's solution, therefore, cannot be 
altered by changing its alkaline base and still retain any 
accuracy as a quantitative test for sugar according to its original 
ratio of reduction. 

3. The Author's Method. — In view of the fact that the deter- 
mination of sugar in the urine had never been rendered entirely 
satisfactory for practical every-day work, the author, about four 
years since, devised the following formula, 1 with the object of 
eliminating the defects of the copper test for quantitative work, 
and also for bringing out the best results of the titration method. 
The four years' subsequent use of this test justifies its recommen- 
dation for the uses for which it was designed. 

The formula for the author's standard solution is as follows : 
Cupric sulphate (C. P.), 4.742 grammes; potassium lrydroxid 
(caustic potash) (C. P.), 23.50 grammes ; strong ammonia 
(IT. S. P.) (sp. gr. 0.9), 450 cubic centimetres; gtycerin (C. P.), 
38 cubic centimetres; distilled water, to 1000 cubic centimetres 
(1 litre). 

Prepare by dissolving the cupric sulphate and glycerin in 
200 cubic centimetres of distilled water with the aid of gentle 
heat. In another 200 cubic centimetres of distilled water dis- 
solve the potassium hydrate. Mix the two solutions, and when 
cold add the ammonia. Finally, with distilled water bring the 

1 The formula has since been improved and standardized in both the metric 
and English systems of weights and measures. 



ABNORMAL CONSTITUENTS OF URINE. 



Ill 



volume of the whole to exactly 1000 cubic centimetres (1 litre). 1 
Thirty-five (35) cubic centimetres of this solution are reduced 
upon boiling by exactly 2 centigrammes (0.02 gramme) of grape- 
sugar. 

The analysis should be conducted as follows : Have on hand 
a glass flask (150 to 200 cubic centimetres' capacity), a common 
retort-stand, a 10-cubic-centimetre or 20-cubic-centimetre gradu- 
ated burette, and a large spirit-lamp. 2 




Fig. 



-The Author's Apparatus for Quantitative Determination 
of Sugar in Urine. 



Proceed by accurately measuring 35 cubic centimetres of the 
solution into the flask, dilute with about 2 volumes of distilled 
water, and bring the whole thoroughly to the boiling-point. Fill 



1 It is important that the glycerin be chemically pure. The ammonia 6hould 
be U. S. P. strength, sp. gr. 0.9 ; that sold as chemically-pure, strong ammonia- 
water is best. 

3 Richards & Co., 112 and 114 Lake Street, Chicago, prepare and keep in 
stock the above solution, as well as the apparatus required for testing. 



112 ANALYSIS OF URINE. 

the burette to the zero-mark with the urine to be tested, and 
slowly discharge the urine into the boiling test solution drop by 
drop, until the blue color begins to fade ; then still more sloivly, 
three to five seconds elapsing after each drop, until the blue 
color completely disappears and leaves the test solution per- 
fectly transparent and colorless. 1 

The number of cubic centimetres it requires to discharge the 
blue color in 35 cubic centimetres of the test solution contain 
exactly 2 centigrammes (0.02 gramme) of sugar. 

The following, therefore, is the percentage relationship of 
reduction of the test : — 

If 35 cubic centimetres of the test solution be reduced by 2 
cubic centimetres of urine, there is exactly 1 per cent, of sugar ; 
reduced by 1 cubic centimetre, 2 per cent. ; reduced by j cubic 
centimetre, 3 per cent. ; reduced by \ cubic centimetre, 4 per 
cent. ; reduced by \ cubic centimetre, 8 per cent. 

If absolute accuracy of results be desired, it is better to dilute 
the urine to be tested with 2 volumes of distilled water and divide 
the product b} r 3, especially if the percentage of sugar be high. 

Those who prefer to work with the English weights and 
measures may obtain the same accuracy of results by using the 
following formula and methods : — 

Sulphate of copper, C. P., .... 44 grains. 

Caustic potash, C. P., 214 grains. 

Strong ammonia, U. S. P. (sp. gr. 0.9), . . 9 fluid ounces. 
Glycerin, C. P., . . . . . . . 6 drachms. 

Distilled water, to 20 ounces. 

Prepare by dissolving the sulphate of copper and gpycerin in 
4 ounces of distilled water, with the aid of gentle heat. In an- 
other 4 ounces of distilled water dissolve the caustic potash. 
Mix the two solutions, and when cold add the ammonia. Finally, 
with distilled water bring the volume of the whole to exacts 20 
fluidounces. 

Ten drachms of the above solution are reduced upon boiling 

1 It will he noted after testing, that upon standing some time the test solu- 
tion resumes the hlue color again. This is due to absorption of oxygen from the 
atmosphere, which reforms the blue protoxide of copper from the cupric sub- 
oxide held in solution by the ammonia. This should not be mistaken for imper- 
fect reduction or defect in the test solution. 



ABNORMAL CONSTITUENTS OF URINE. 113 

by exactly J grain of grape-sugar. The test is conducted pre- 
cisely as already described in the metric system, save that a 
minim burette is substituted for the cubic-centimetre burette 
and the result is reckoned in grains instead of grammes. 

To determine the number of grains of sugar per ounce in any 
given sample of urine, divide 480 (the number of grains per 
ounce) by the number of minims it required to discharge the 
blue color in 10 drachms of the test solution ; divide the product 
by 3 and the result is the number of grains per ounce. 

Example. — If 16 minims of urine reduce 10 drachms of the 
test solution, there are 10 grains of sugar per ounce, — 

480 . _ _, n . „ 

— 3 :=10 grams of sugar. 

16 & 

If it be desired to know the percentage amount of sugar 
present, divide the number of grains per ounce by 4.8. 

The advantages claimed for the above test are as follow: 
1. Its perfect end reaction, whereby even the inexperienced ob- 
server may accurately determine the precise point of complete 
reduction without delajr. 2. Its stabilit} T , which is such that 
the solution ma}^ be kept on hand for months without impair- 
ment of its qualities for testing. 3. Its rapidity of application, 
by means of which one is enabled to determine the quantity of 
sugar in a given sample of urine within five minutes. 4. Its 
accuracy, which any one may readily prove by submitting to it 
solutions of grape-sugar in normal urine of known and accu- 
rately-measured strength. 5. Its simplicity, the apparatus 
required being of the most common order. 

4. Optical Sac char imetry. — As already stated, grape-sugar 
possesses a right rotatory power over polarized light, and upon 
this fact has been based a method of quantitative testing for 
sugar by the polariscope. Among the more elaborately-con- 
structed instruments for this purpose are those of Lippich, 
Misterlich, Soleil, Laurent, Wild, and von Fliesehel. 

Ultzmann has devised a polarizing saccharimeter, which pos- 
sesses several important advantages over the instruments named, 
as follows : (a) No artificial light is needed, for the concave 
mirror of the microscope-stand brilliant!}' illuminates the field 



114 



ANALYSIS OF URINE. 



of vision, (b) The apparatus itself is small, scarcely longer 
than the elongated tube of the ordinary microscope, and needs 
no separate stand, (c) By means of this instrument the per- 
centage of sugar can be directly calculated, (d) The entire 
apparatus can be had for a comparatively small cost. 




Fig. 10.— Ui/tzmann's Polarizing Sacchaeimetee Adjusted to 
Microscope-Stand. 



In using this saccharimeter, the tube, objectives, and ocular 
of the microscope are removed, and in their place the sacchari- 
meter is inserted and made fast by means of a small screw. The 
concave mirror is then adjusted, and, by looking through the 



ABNORMAL CONSTITUENTS OF URINE. 



115 



d 



instrument, it is determined whether or not it is properly ad- 
justed. 

In Fig. 11 a is the biconcave and b the objective lens of a 
small Dutch telescope, the focal distance of which extends to p ; 
c is the upper Nicol prism, with which a vernier is closely con- 
nected ; d is a glass tube for holding the suspected fluid, which 
should be filtered or otherwise cleansed 
before analysis ; p is a double plate of 
right and left rotating quartz, and f 
the lower Nicol prism. 

The arc or fixed scale is so divided 
that one division of it represents 1 per 
cent, of grape-sugar at a temperature 
of 20° C. By means of the vernier, 
tenths of a degree (i.e., of 1 per cent.) 
can be approximately determined. 
Since 10 degrees of the vernier corre- 
spond exactly with 9 degrees of the 
arc, to the percentage of sugar found 
must be added as many tenths as 
spaces are counted on the vernier up 
to that division which exactly coincides 
with a division of the arc. 

If, for example, the zero-point of 
the vernier does not quite reach 
(toward the right) the 5-point of the 
scale, it indicates that the percentage 
of sugar is more than 4 and less than 
5 per cent. If it be desired to esti- 
mate the tenths per cent., and the sixth 
division of the vernier is the first 
(counted from the zero-point) to co- 
incide with a division of the arc, then 6 is the number of 
tenths required, and the apparatus would indicate, in this case, 
4.6 per cent, grape-sugar present. In estimating the strength 
of cane-sugar solutions, it is to be borne in mind that the 
polarization power of cane-sugar is three-fourths that of 
grape-sugar. 



-/ 



Fig. 11.— Sectional View 
of Ultzmann's Polariz- 
ing Saccharimeter. 



116 ANALYSIS OP URINE. 

Cane- and grape- sugar, as well as lactose, turn the polarized 
ray to the riglit, while albumin and levulose, on the other hand, 
turn it toward the left. If the glass tube of the saccharimeter 
be empty, or contain a fluid holding in solution substances 
having no optical influence (as normal urine), the zero-point of 
the vernier coincides exactly with the zero-point of the scale, 
and the two halves of the field of vision are exactly isochro- 
matic. If, on the contrary, an optically-active substance be 
contained in the fluid, — as, for example, sugar, — the normal 
isochromatism of the two halves disappears, and a distinctly 
unequal coloring takes place. This is the more apparent the 
greater the amount of optical^-active substance present in 
solution. When this unequal coloring occurs the vernier is to 
be moved toward the riglit or left (according to the presence of 
sugar or albumin) until the color of the two halves is again 
exactly the same. The percentage is then read off the scale in 
the way above mentioned. 

If a diabetic urine be very light colored and clear, it can at 
once be put into the glass tube of the instrument and the 
determination made. If, however, it be dark and cloudy, and 
contain albumin, it is advantageous to first clarify it and remove 
all disturbing substances. This is best accomplished by means 
of a 10-per-cent. aqueous solution of sugar of lead. The lead 
acetate causes in urine a copious white precipitate, consisting of 
lead chloride, phosphate, and sulphate, and the precipitate 
carries down with it all the coloring matter of the urine and such 
albumin as ma} 7 be present. If the urine be then passed through 
a dry filter, the resulting filtrate is almost as clear as water, and 
is particularly well adapted for the apparatus. Since, however, 
the amount of sugar in the mixture (after the addition of the 
lead-acetate solution) differs from that in the urine, the amount 
of dilution must be taken into account in estimating the sugar 
present. It is best, therefore, to take 75 cubic centimetres of 
urine, and to that add 25 cubic centimetres of lead-acetate solu- 
tion, shake, and filter. In estimating the sugar present in the 
urine, one-third of the percentage of the mixture added to that 
percentage will give the percentage of sugar in 100 cubic centi- 
metres of urine. In other words, the percentage of the mixture 



ABNORMAL CONSTITUENTS OF URINE. 117 

is three-quarters that of the urine. Thus, if to 75 cubic centi- 
metres of a dark, albuminous, saccharine urine have been added 
25 cubic centimetres of lead-acetate solution, the mixture filtered, 
and found to contain 4.8 per cent, sugar, then 1.6 per cent, must 
be added to give the percentage in 100 cubic centimetres of 
urine, which would, therefore, contain 4 8 -j- 1.6 per cent. = 6.4 
per cent, sugar. In filling the glass tube care must be observed 
that no air-bubbles are included in the fluid. It is well, there- 
fore, to fill the tube as full as possible and push the glass 
cover on from one side before screwing down the cover (Ultz- 
mann). 

The author uses this instrument, obtaining fairly rapid and 
satisfactory results if the quantity of sugar be over 1 per cent., 
but in quantities much less than this the results are uncertain. 

Levulosuria. 

Fruit-sugar, or levulose, has been found in the urine of per- 
sons whose symptoms correspond closely with those of diabetes 
mellitus. In such cases the levulose may be associated with 
grape-sugar, or it may appear alone, but usually the former is 
the case. 

Levulose turns the plane of polarization to the left, and this 
fact enables us to distinguish it from grape-sugar, which turns it 
to the right. Levulose reduces copper salts as does grape-sugar, 
although more feebly than the latter. It also yields the charac- 
teristic reaction of yellow crystallization with phenylhydrazin 
lrydrochloride, but these crystals melt at 150° C, while those 
formed from grape-sugar require a temperature of 204° C. to 
melt them. Levulose does not crystallize, and does not melt so 
readily as does grape-sugar. When cane-sugar is treated with 
dilute mineral acids, it undergoes a process known as inversion, 
— i.e., it takes up water and is converted into a mixture of equal 
parts of dextrose and levulose. 

Clinical Significance. — Aside from the fact that levulose is 
sometimes found in the urine in diabetic conditions, either alone 
or, as is more common, in association with grape-sugar, little else 
is known of its clinical relations. It has been stated that excess- 
ive ingestion of cane-sugar, as well as the sugars of certain kinds 



118 ANALYSIS OF URINE. 

of fruits, may cause the appearance of levulose in the urine, more 
especially in conditions of disturbed digestion. This, however, is 
rather conjectural than the result of observation, although cane- 
sugar is converted in the intestines into glucose and levulose. 

Detection. — If saccharine urine deflect polarized light strongly 
to the left, we may infer that the saccharine substance is levulose. 
If other known substances which turn polarized light to the left 
be excluded, it may be regarded as certain that levulose is 
present. 

Lactosuria. 

Lactose, or milk-sugar, crystallizes in white, rhombic prisms, 
which are soluble in 6 parts of cold and 1\ parts of hot water. 
It has only a faintly-sweet taste, and is insoluble in alcohol and 
ether. Aqueous solutions of lactose possess a right, or dextro- 
rotatory, power over polarized light of -f- 59.3°, and do not 
readily undergo alcoholic fermentation. It reduces the copper 
salts upon boiling in alkaline solutions, but about one-third less 
powerful^ than does grape-sugar. If long boiled with dilute 
acids, it forms galactose, which, treated with nitric acid, yields 
mucic acid. 

Clinical Significance. — Lactose occurs frequently in the urine 
of women who are nursing, the quantity usually being small, 
although it may reach as high as 3 per cent., and be attended by 
all the usual symptoms of diabetes, as in a case reported by 
Ralfe, at the London Hospital. In this case the woman was suf- 
fering from debility, and lactosuria occurred after three success- 
ive confinements, the urine being free from sugar during the 
gestation. 

Lactose is nearly always present in the urine of women two 
or three days after confinement, and just before milk appears in 
the mammary glands (during milk fever) ; and the same ma}' be 
said of women within a day or two after weaning their children. 
Lactosuria may also arise from any cause that prevents the milk 
escaping from the mammary glands during lactation, such as 
inflammations involving the mammary ducts. 

Detection. — If urine give the characteristic reaction of grape- 
sugar with alkaline solutions of cupric salts, and if it also cause 
extreme deflection of the polarized ray to the right, it is prob- 



ABNORMAL CONSTITUENTS OF URINE. 119 

able that lactose is present. Confirm by treating the urine with 
an excess of lead acetate, filter, and to the filtrate add ammonia 
until a permanent precipitate forms. The fluid is then heated, 
but not boiled ; and if a rose-red color gradually develop, which 
slowly vanishes on standing, grape-sugar is present ; if no such 
reaction occur, lactose is present (Rubner). 

Inosituria. 

Inosite, or muscle-sugar, crystallizes in large, colorless, mono- 
clinic prisms, sometimes grouped in rosettes. They are soluble 
in 6 parts of water at 20° C, insoluble in alcohol and ether. 
Inosite does not undergo alcoholic fermentation, and possesses 
no rotatory power over polarized light. It does not reduce 
alkaline solutions of cupric salts, although it gives with them 
a greenish tint upon boiling, which clears up on standing, and 
again turns green on boiling. 

Although termed muscle-sugar, inosite has been found in the 
lungs, spleen, liver, kidnej's, and brain, and it has been found in 
the urine in a number of pathological conditions. 

Clinical Significance. — Inosituria has frequently been noted 
in association with diabetic conditions. It has also been ob- 
served in typhus, phthisis, syphilitic cachexia, and in diseases 
of the medulla. In a number of cases of inosituria Ralfe 
observed moderate polyuria, loss of flesh, general malaise, and 
aching in the limbs, although no tangible disease could be made 
out. Inosituria not infrequent^ takes the place of glycosuria, 
especially in the milder grades of diabetes or in convalescence 
from the latter. Inosituria is also occasionally associated with 
albuminuria in Bright's disease. Gallois found inosite in the 
urine of 7 out of 102 patients examined. Of these, it occurred 
5 times in 30 cases of diabetes and in 25 cases of albuminuria. 

Detection. — 1. If a solution of inosite be evaporated with a 
little nitric acid on platinum almost to dimness, and the residue 
be moistened with a little ammonia and solution of calcium 
chloride, and the mixture again be evaporated carefully to dry- 
ness, a vivid rose-red or violet color arises, which is apparent 
with even 1 milligramme of inosite (Scherer). Other sugars do 
not give this reaction. 



120 ANALYSIS OF URINE. 

2. Add a little mercuric nitrate solution r to a solution of inosite 
on a porcelain dish ; a 3 T ellow precipitate is produced. On heat- 
ing this gently it will become red ; on cooling the color van- 
ishes, but re-appears again on gently heating. Uric acid, urea, 
starch, lactose, mannite, glycocoll, tannin, cystin, and glycogen 
do not give this reaction. Albumin is colored red and grape- 
sugar black, and therefore, if present, these should be removed. 

3. Inosite may be isolated from the urine, as follows : After 
first removing the albumin, if present, the urine is treated with 
neutral lead acetate until precipitation ceases. It is then filtered 
and the warmed filtrate treated with subacetate of lead as long- 
as any precipitate occurs. It is well to concentrate the urine to 
one-fourth of its bulk before precipitation. The lead precipitate 
containing the inosite combined with lead oxide is collected 
after twelve hours, and, after washing, is suspended in water 
and decomposed with sulphuretted hydrogen. A little uric acid 
first separates upon standing awhile ; the fluid is separated 
therefrom by filtration and the filtrate concentrated by boiling, 
and is treated with three or four volumes of alcohol while boil- 
ing. A heavy precipitate results, and the hot alcoholic solution 
is poured off, unless the precipitate be flocculent and non- 
adhesive, in which case it may be filtered through a heated 
funnel and allowed to cool. If, after twei^-four hours, inosite 
crystals have deposited, as is usual, in groups, the} 7 are filtered 
and washed with cold alcohol. If, however, no crystals of 
inosite have separated, ether is added to the clear, cold, alcoholic 
filtrate until a milky cloudiness results upon standing, and it is 
then allowed to stand in the cold for twenty-four hours. If too 
little ether has not been employed, almost all of the inosite 
present is separated in the form of shining, pearly leaflets. 

Allied Substances Occasionally Found in Urine, 
glycuronic acid. 

This substance is closely allied to carbohydrates, its formula being C 6 H 10 O 7 . 
When pure it is not crystalline, but its anhydride forms colorless, acicular crys- 
tals. It is insoluble in ether, but soluble in water and hot alcohol, crystallizing 

1 Prepared by dissolving 1 part of mercury in 2 parts of nitric acid, and 
evaporate to one-half and add \y 2 parts of water. After twenty-four hours, pour 
the clear fluid from the basic salt. 



ABNORMAL CONSTITUENTS OF URINE. 121 

out from the latter on cooling. Though so closely related chemically to the car- 
bohydrates, it yields, with urea, decomposition products of an aromatic nature, 
as orthonitrobenzyl alcohol. It occurs in the urine as a potassium salt, 
C 6 H 9 K0 7 . Bromine converts glycuronic acid into saccharic acid, indicating its 
close relationship to dextrose, as well as to the aldehyde group. It has been 
thought to arise from dextrose in the organism, though Kulz suggested its 
origin to be from inosite. 

Glycuronic acid, of all substances met with in the urine, is most likely to be 
mistaken for grape-sugar, since it gives a heavy yellow or even red precipitate 
with cuprous oxide, reduces bismuth, silver, and mercury salts, and is dextro- 
rotatory. 

Significayice. — Glycuronic acid occurs in the urine abundantly after the ad- 
ministration of such drugs as chloral and butyl-chloral, nitrobenzol, camphor, 
curare, morphia, chloroform, etc., in consequence of which it was formerly 
thought that the use of these substances caused the appearance of grape-sugar 
in the urine. It sometimes, though not frequently, occurs in the urine of people 
who are apparently in good health and are not diabetic ; so that it is important 
to distinguish between this condition and glycosuria. 

Detection. — 1. If the urine reduce cupric oxide and is dextro-rotatory, but 
fails to undergo alcoholic fermentation with the yeast test, glycuronic acid is 
present. 2. It may be isolated from the urine by the method of Schmiedeberg and 
Mayer, as follows : A large quantity of urine is decolorized by animal charcoal, 
evaporated to a syrup, and then digested with large quantities of damp barium 
hydrate in the presence of gentle heat over a water-bath. It is then extracted 
with absolute alcohol ; glycuronic acid and other substances are left undissolved. 
The residue is mixed with water and filtered ; more baryta is added to the filtrate ; 
it is again filtered, and the filtrate evaporated down over a water-bath. An amor- 
phous barium compound separates out ; this is washed with water, decomposed 
by sulphuric acid ; the barium sulphate is filtered off, the filtrate is evaporated 
down and dried in vacuo, when crystals of the anhydride will be obtained. 

CANE-SUGAR. 

After abundant use of cane-sugar as food, traces of it may be found in the 
blood and sometimes in the urine. Pure cane-sugar possesses no reducing power 
over cupric oxide ; but as met with commercially it sometimes contains other 
sugars as impurities, which may cause slight reduction of the copper tests. 

Cane-sugar crystallizes in monoclinic prisms, aqueous solutions of which 
possess strong dextro-rotatory powers + 73.8°. By boiling with water, or more 
readily with dilute mineral acids, it undergoes inversion, — i.e., it takes up water 
and separates into dextrose and levulose. Nitric acid oxidizes cane-sugar into 
saccharic acid. 

Detection. — It has been stated that if cane-sugar be boiled some time in water 
it undergoes inversion, becoming glucose and levulose. With solutions of cane- 
sugar the polarization is dextro-rotatory, but after inversion it becomes levulo- 
rotatory, because the left-handed action of the molecule of levulose produced 
= — 106° is only partly neutralized by the right-handed action of the glucose 
= +56°. 



122 ANALYSIS OF URINE. 

GLYCOGEN. 

This substance is found in the liver, muscles, placenta, white blood-corpus- 
cles, cartilage-cells, pus-cells, and in embryonic tissues. It has also been found 
in the urine, notably in some diabetic conditions. Pure glycogen is a snow-white, 
amorphous powder, tasteless and odorless, soluble in water, insoluble in alcohol 
and ether. Glycogen is strongly dextro-rotatory + 211°, but does not reduce 
cupric oxide. Glycogen gives with iodine a port-wine red color ; the color dis- 
appears on heating, and re-appears on cooling. 



SECTION V. 

ABNORMAL URINE (continued). 

ACETONURIA. 

Acetone — C 3 H e O — is a thin, watery, colorless liquid, of spe- 
cific gravity 0.792, which boils at 56.5° C, and possesses a pe- 
culiar ethereal or fruit-like odor. It may be obtained in consid- 
erable quantity by distillation of the urine as well as the blood 
of diabetic patients. Acetone is also sometimes found in the 
urine of children apparently in good health. 

Heated with potassium iodide and potassium hydrate, iodo- 
form is evolved; with solutions of nitroprusside of sodium and 
ammonia a rose-red color is produced. 

Acetone and aceto-acetic acid are sometimes both present in 
the urine, sometimes only one of them. V. Jaksch holds that 
acetone is a normal constituent of urine, though occurring in 
minute quantity (0.1 gramme in twenty -four hours). On the 
other hand Le Noble holds that acetone only occurs in healthy 
urine after the use of alcohol or foods rich in proteids. Both 
acetone and aceto-acetic acid seem to be decomposition products 
of albumins. 

Clinical Significance. — Acetonuria of pronounced degree 
often accompanies high febrile states, probably caused by blood 
changes which result from exalted temperatures, since acetonuria 
belongs to no special form of fever. Moreover, the amount of 
acetone in the urine in febrile conditions corresponds closely 
with the degree of temperature elevation, always rising and fall- 
ing with the latter. 

Acetonuria often occurs in diabetes mellitus, more especially 
in advanced cases. In such cases it sometimes precedes the more 
dangerous symptom of diaceturia. Acetonuria is frequent^ 
associated with certain forms of cancer, notably carcinoma. It 
is also observed in cases of inanition or starvation and in cere- 
bral psychosis, especially if accompanied by great mental excite- 

(123) 



124 ANALYSIS OF URINE. 

ment. Acetonuria may result from excessive use of animal 
foods, and this maj^, in a measure, account for its frequent 
appearance in diabetes, since such patients are usually restricted 
largely to nitrogenous diet. A condition of auto-intoxication 
with acetone sometimes occurs, which is accompanied by aceto- 
nuria. This state gives rise to symptoms of restlessness, excite- 
ment, and even delirium, but unless accompanied by diaceturia 
it tends toward a favorable termination (Jaksch), although it 
may end in coma and death in some cases. 

Acetonuria occurs in association with the following diseases : 
Small-pox, typhus, pneumonia, scarlet fever, measles, Bright's 
disease, perityphlitis, and strangulated hernia, but it is never 
accompanied or followed b} r diabetic coma in such cases. 

Detection. — 1. Lieben's iodoform test, as modified by Ralfe, 
is as follows : 20 grains of potassium iodide are dissolved in a 
drachm of liquor potassse and boiled ; the urine is then floated 
upon the surface of the fluid in a test-tube. At the point of 
contact a precipitation of phosphates occurs, which, if acetone 
be present, becomes } T ellow and studded with yellow points of 
iodoform. 

A more delicate method of application of this test is to first 
distill a small quantity of the urine, and appty the test to the 
distillate. This test has one disadvantage : lactic acid and ethjd 
alcohol behave with it similarly to acetone. 

2. Chautard's Test. — A drop of aqueous solution of magenta 
decolorized by sulphurous acid gives, with fluids containing over 
0.01 per cent, of acetone, a violet color. This appears in dilute 
solutions after four or five minutes. 

3. Le Noble's Test. — On adding an alkaline solution of sodium 
nitroprusside — so dilute as to have only a slight red tint — to a 
fluid containing acetone, a ruby-red color is produced, which in 
a few minutes changes to yellow, and on boiling, after adding 
acid, to greenish blue or violet. A quarter of a milligramme of 
acetone can be thus detected. 

4. Baeyer's Indigo Test. — A few crj-stals of nitrobenzalde- 
hyde are dissolved by heat in the suspected urine ; on cooling 
the aldehyde separates in the form of a white cloud. The mixt- 
ure is thus made alkaline with dilute sodium solution, and, if 



ABNORMAL CONSTITUENTS OF URINE. 125 

acetone be present, first yellow, then green, and lastly an indigo- 
blue color will appear within ten minutes. 

5. Beynolds's Test. — This test depends upon the fact that ace- 
tone promotes the solution of mercuric oxide. The test may be 
conducted as follows : The yellow precipitate of mercuric oxide, 
obtained by the reaction of mercuric chloride with an alcoholic 
solution of potassium hydrate is added to a small quantity of 
the urine, which is shaken and filtered. To the clear filtrate 
ammonium sulphate is carefully added, and if acetone be present 
some of the mercuric oxide is dissolved and a black ring of 
sulphide of mercury appears at the plane of contact between the 
two liquids. 

Diaceturia. 

Diacetic or ethyl-diacetic acid (C 6 H 10 O 3 ) is a colorless, 
strongly-acid liquid which mixes with water, alcohol, and ether in 
all proportions. On heating to boiling with water, especially with 
acids, diacetic acid decomposes into carbon dioxide and acetone. 
It differs from acetone in giving a violet-red or brownish-red 
mahogany color with solution of ferric chloride. This color 
decreases at ordinary temperatures within twenty-four hours, 
and more rapidly upon boiling, in which respects it differs from 
phenol, salicjdic acid, acetic acid, and sulphocyanides. 

Diacetic acid has frequently been confused with and mistaken 
for acetone. Under the influence of alkalies it takes up water 
and splits into acetone, alcohol, and carbonic acid : — 

C 6 H 10 O 3 +H 2 O = C 3 H 6 O + C 2 H 6 O + CO 2 . 

If this take place in the blood or urine, it is probably the 
sodium salt which undergoes similar decomposition : — 

C 6 H 9 Na0 3 -f2H 2 = C 3 H 6 + C 2 H 6 -f NaHC0 3 . 

Sodium-ethyl Acetone Alcohol Sodium-hydrogen 

diacetate. Acetone. Aiconoi. carbonate. 

This view of the origin of acetone is supported by the fact 
that alcohol is often found in the urine at the same time. There 
are, it is true, other substances in the urine at times which give, 
under certain circumstances the ferric-chloride reaction, — viz., 
/^-hydroxy butyric acid,sulpho- (thyo-) c}^anates, acetic acid, and 
formic acid ; and, according to Legal and Hammarsten, the urine 



126 ANALYSIS OF URINE. 

of patients who have taken thallin, antipyrin, salicylic acid, and 
carbolic acid may give the reaction. If, however, as already 
stated, the urine be previously boiled, diacetic acid still gives 
the ferric-chloride reaction, while the other substances do not. 
Fleischer found that the substance which gives the ferric-chlo- 
ride reaction in the urine is not taken up by ether after the urine 
is acidulated with sulphuric acid, whereas diacetic acid is soluble 
in ether. Salkowski confirmed this observation, and found, more- 
over, that the urine, after boiling, did not give the ferric chloride 
reaction. These last-named observers hold that in most cases it 
is not diacetic acid from which acetone originates, but some 
at present unknown substance, possibly hydroxybutyric acid 
already mentioned (Halliburton). 

Clinical Significance. — Diaceturia is always pathological, and, 
for the most part, it may be regarded as a symptom of serious 
import. It is of least serious significance when occurring, as is 
not uncommon, in febrile conditions in children. Under such 
circumstances recovery usually follows. In the case of adults 
it is always of more grave significance. In diabetes the occur- 
rence of diaceturia may be looked upon as the almost certain 
prelude to coma, which usually terminates quickly in death. Yon 
Jaksch, indeed, considers that diabetic coma is due to the pres- 
ence of diacetic acid in the blood, and he, therefore, proposes to 
substitute the term diacetic coma for the former name. 

Diaceturia is most common in the advanced stages of dia- 
betes, and more especially in young subjects of the disease. It 
does not, apparently, depend upon large quantities of sugar in 
the urine, at least directly so, since the appearance of diaceturia 
is often preceded by decided diminution of sugar. 

It sometimes occurs at the height of acute fevers, and in 
adults such occurrence is of grave significance. 

Diaceturia is sometimes the index of auto-intoxication — di- 
acetsemia — and is accompanied by such s}^mptoms as vomiting, 
dyspnoea, jactitation, which shortly ends in coma and death 
without other discoverable disease or lesion. 

Detection. — This is best accomplished by v. Jaksch's method, 
as follows : Take a recently-voided sample of urine, and add a 
few drops of ferric-chloride solution thereto. If the phosphates 



ABNORMAL CONSTITUENTS OF URINE. 127 

be precipitated filter them off, and to the filtrate add a few drops 
more of ferric-chloride solution. If a red color is produced, boil 
a portion of the urine, and to another portion add a few drops of 
sulphuric acid and shake with ether. If the red color appear 
but slightly or not at all in the boiled portion, and grows pale 
after twenty-four hours in the ethereal extract, and, furthermore, 
acetone be detected in considerable quantity in the distillate, 
diacetic acid is present. 

Choluria. 

The biliary acids and pigments are the chief bile-elements of 
clinical interest met with in the urine. 

BILIARY ACIDS. 

It is an unsettled question as yet if the bile-acids occur in 
the urine under physiological conditions. According to Yogel, 
Dragendorff, Hone, and Oliver, traces of bile-acids occur in 
normal urine, although Hoppe-Seyler and Udransky hold the 
opposite view. Oliver's new and delicate method of testing for 
the bile-acids gives his results much weight, and it may be as- 
sumed that the evidence is in favor of the view that the bile- 
acids are present in minute quantities in the urine of health. 

Clinical Significance. — Dr. Oliver estimates the amount of 
bile-salts in normal urine as about 1 part in from 10,000 to 15,000 
parts. Furthermore, in a series of observations he has noted 
that the normal percentage quantity varies with the time of day, 
reaching the maximum during periods of fasting, as in the 
morning urine and that passed before meals ; while it quickly 
diminishes after meals, reaching the minimum about three hours 
after food. Dr. Oliver also observed an increase of the bile-acids 
in the urine upon active muscular exertion ; and he suggests 
that changes of temperature, atmospheric pressure, use of alcohol, 
etc., also influence the degree of discharge of the bile-salts by 
the kidneys. The bile-salts in the urine are markedly augmented 
in all forms of jaundice, and, moreover, according to Oliver's 
observations, this occurs both before the appearance of the bile- 
pigments and long after their disappearance from the urine. 

In so-called acute bilious attacks — i.e., biliaiy engorgement 



128 ANALYSIS OF URINE. 

from defective bile excretion — there appears to be an overflow of 
the bile-elements into the blood, accompanied by such symptoms 
as feeble pulse, pallor, coldness of the extremities, sensations of 
chilliness, slow respiration, nausea and vomiting, with headache, 
and sometimes diarrhoea. During these symptoms the bile-salts 
in the urine are at first diminished, but after a time they are in- 
creased, and thereupon immediate relief from these symptoms 
follows. 

Acute cholsemia from retention of bile-salts in the blood may 
pass beyond the ordinary bilious attack and produce the more 
serious symptoms of lowered temperature, convulsions, albumi- 
nuria, with evidences of blood dissolution such as hsemo- 
globinuria. 

Hepatic congestion, early cirrhosis, and malarial poisoning- 
are accompanied by increased elimination of the bile-acids in the 
urine, more especially if accompanied by constipation. Dr. 
Oliver has noted excess of the bile-acids in the urine in carci- 
noma, amyloid disease, enlargement of the liver, cirrhosis, and 
in hepatic tumors. Choluria always follows a rise of tempera- 
ture, and in high fevers the increase of bile-acids may reach 400 
per cent, above the normal range. In splenic leucocj'thaemia, 
anaemia, haemoglobin uria, and scurvy a large excess of the bile- 
acids appears in the urine. Lastly, Dr. Oliver has noted 
a decided and persistent decrease of the bile-acids in the urine 
in cases of chronic interstitial nephritis, — granular kidne} T . 1 

1 In view of the fact that nearly all advanced chemico-physiologists are now 
agreed that the liver constitutes the chief agent of destruction of those sub- 
stances which we know to be auto-intoxicants to the organism, Dr. Oliver's 
explanation of the hepatic origin of certain symptoms seems to the author vastly 
more reasonable than the explanation of many of the same symptoms by Haig's 
uric-acid theories. The author has searched in vain among the classic experi- 
ments of Bouchard, as well as others, for proof that uric acid is in any way toxic 
to the organism, even when injected into the blood in the enormous dose of 0.64 
gramme per kilogramme of body-weight. On the other hand, the bile-salts are 
toxic in almost infinitesimal doses ; they are not only toxic, but in aqueous solu- 
tions of 2 per cent, they kill 1 kilogramme of weight ; the cholate of sodium in dose 
of 54 centigrammes, and cholate of potassium in dose of 46 centigrammes. The 
enormous toxic power of bile, as a whole, may be judged from the following 
statement of Bouchard as a result of direct experimentation : " We must conclude 
that during twenty-four hours a man makes, by the activity of his liver alone, 
enough poison to kill three men of his own weight." 



ABNORMAL CONSTITUENTS OF URINE. 129 

Detection. — 1. Pettenkoffer's method is as follows : The urine 
is mixed with concentrated sulphuric acid, taking care that the 
temperature does not rise higher than 60° to 70° C. Then a 
10-per-cent. solution of cane-sugar is added drop by drop, con- 
tinually stirring with a glass rod. The presence of bile-acids is 
indicated by the production of a beautiful red liquid, the color 
not disappearing at ordinary temperature, but becoming more 
bluish violet in the course of a day or so. This red liquid shows 
a spectrum with two absorption bands, the one at i^and the 
other between D and E near E. 

This test fails if the solution be heated too high or an im- 
proper quantity — usually too much — sugar be added. In the 
last case the sugar carbonizes and the test becomes dark brown 
or brown. The reaction fails if the sulphuric acid contains sul- 
phurous acid or the lower oxides of nitrogen. Since many other 
substances, such as albumin, oleic acid, amylalcohol, morphine, 
give a similar reaction ; in doubtful cases the spectroscopical 
examination must not be omitted. 

If the urine be icteric and of pronounced color, the bile-acids 
must first be isolated from the urine by Hoppe-Seyler's method 
before applying the above test, as follows : Strongly concentrate 
the urine and extract the residue with strong alcohol. The 
filtrate is freed from alcohol by evaporation and then precipitated 
by basic lead acetate and ammonia. The washed precipitate 
is treated with boiling alcohol, filtered hot, the filtrate treated 
with a few drops of sodium solution, and evaporated to diyness. 
The dry residue is extracted with absolute alcohol, filtered, and 
an excess of ether added. The amorphous or, after a longer 
time, ciystalline precipitate, consisting of alkali salts of the 
biliary acids, may then be submitted to the above-described test. 

2. Dr. Olive?^s method of detecting the bile-acids is most 
sensitive and simple. The principle of this method depends 
upon the physiological fact that such products of gastric diges- 
tion as peptone and propeptone are precipitated in the duodenum 
by contact with the bile-acids. Therefore, since peptone in an 
acid solution, as the urine, is precipitated b}^ the bile-acids or 
their derivatives as cholate of sodium, 1 an acid solution of 
1 The form in which the bile-acids occur in the urine. 



130 



ANALYSIS OF URINE. 



peptone may be used as a test for the bile-acids. The following 
is the formula for the test solution : Pulverized peptone (Savory 
and Moore's), 3 s s ; salicylic acid, 4 grains ; acetic acid, 5 SS ; 
distilled water to 8 ounces. To be filtered repeatedly until 
rendered transparent. In testing, the urine must be perfectly 
cleansed, if not already so, and rendered acid if it be alkaline or 
neutral, and the specific gravity reduced to 1008 if it be above 
it. To 60 minims of the test solution 20 minims of the urine 
are added. If bile-acids be present in normal amount, there 
will be no immediate reaction visible, but shortly a slight tinge 
of milkiness will be produced. If in excess, a distinct milkiness 
at once appears, becoming more intense in proportion to the 
quantity of bile-acids present. On agitation the opalescence 
diminishes, and may even disappear, but it returns upon the 
addition of more of the test solution. On this fact is based an 
approximate quantitative test, for which is prepared a standard 
solution b t y adding equal parts of test fluid and normal urine 
diluted to specific gravity 1008. Ai^ urine requiring 60 minims 
or more to bring its opacity up to that of the standard does not 
contain an excess of bile-acids. 









Dr. Olivek 


s Standard 


Table. 








Urine 




Percentage Increase 




Urine 






Percentage Increase 








of Bile-Salts O 


er 










of Bile-Salts Over 


iniins 




Drops. 


the Normal. 




Minims 




Drops. 




the Normal. 


1 


or 


2 


= 6000 




20 


or 


40 


= 


300 


2 


or 


4 


= 3000 




25 


or 


50 


— 


240 


3 


or 


6 


= 2000 




30 


or 


60 


= 


100 


4 


or 


8 


= 1500 




35 


or 


70 


= 


83 


5 


or 


10 


= 1200 




40 


or 


80 


= 


66 


10 


or 


20 


= 600 




45 


or 


90 


= 


50 


15 


or 


30 


= 400 















Percentage increase over 100 above the normal is rarety 
encountered. With the above test Dr. Oliver detects 1 part of 
bile-salts in 18,000 or 20,000 parts of sodium-chloride solution. 
If careful attention be paid to details in preparation of the 
urine, nothing as yet found in urine interferes with the test. 



BILIARY PIGMENTS. 



Bile coloring matters appear in the urine in a number of con- 
ditions. The urine in such cases is always abnormally colored, 
— yellow, 3'ellowish brown, deep brown, greenish yellow, green- 



ABNORMAL CONSTITUENTS OF URINE. ',31 

ish brown, or even nearly pure green. On shaking the urine it 
froths and the bubbles are yellow or yellowish green in color. 
The morphological elements of the sediment often take the color 
of the abnormal pigment in the urine. 

Clinical Significance. — The biliary pigments are met with in 
the urine in jaundice, from whatever cause it arises, but most 
commonly, perhaps, when due to obstruction of the bile-ducts. 
In such cases the bile-elements make their way into the 
lymphatics and the general circulation and are eliminated by 
the kidneys. The bile-pigments appear in the urine several 
days before the icteric coloration of the skin is perceptible, and 
therefore they may sometimes be taken as a prognostic of the 
approach of jaundice. 

The biliary coloring matters are also found in the urine in 
numerous pathological conditions of the liver, in which icterus 
may or may not be present also. They may also appear in the 
urine as a result of blood changes, and after haemorrhage into 
the tissues ; and in such cases they are derived from their 
primary source in the blood itself. Lastly, bile-pigments in large 
amounts always appear in the urine in cases of phosphorus 
poisoning. 

Detection. — 1. Gmelin's method consists in introducing a 
column of strong nitric acid, containing a little yellow nitrous 
acid of commerce (HN0 3 -f N0 3 ) into a test-tube, and upon this 
gently floating a column of similar depth of urine. In the zone 
between the fluids appears from below upward the colors green, 
blue, violet, red, and yellow. The green is most predominant, 
while the blue is most indistinct or sometimes absent. 

(a) In Rosenbach's modification of this test the urine is fil- 
tered through a fine, thick filter. After filtration a drop of 
nitric acid containing a little nitrous acid is applied to the inside 
of the filter. A pale-yellow spot will be formed, which is sur- 
rounded by colored rings which appear yellowish red, violet, blue, 
and green. This modification is very delicate, and it is hardly 
possible to mistake other coloring matters for the bile-pigments. 

(b) Dragendorff has adopted still another modification of the 
above test, which consists in placing a little of the urine on a 
plaster-of-Paris disc, and, when nearly absorbed, a drop of nitric 



132 ANALYSIS OF URINE. 

acid is allowed to fall on the moistened spot. If the bile-pig- 
ments be present a ring forms about the acid drop, in which 
green is predominant. 

2. Huppertfs test detects the faintest traces of bile-pigment 
in the urine. The urine is treated with lime-water, or first with 
some CaCl 2 solution, and then with a solution of sodium or am- 
monium carbonate. The precipitate, consisting of bile-pigments, 
ma} T be shaken out with chloroform after washing in water, and 
after acidification with acetic acid. The bilirubin is taken up by 
the chloroform, which is colored yellow thereby, while the acetic- 
acid solution is colored green by the bilirubin. 

The lime-pigments may also be used directly for GrmehVs test 
in the following way : Spread them on a porcelain dish in a thin 
layer, and add a drop of nitric acid. The reaction usually appears 
very beautiful. 

3. Ultzmanns test consists in treating 10 cubic centimetres 
of the urine with 3 or 4 cubic centimetres of concentrated caustic- 
potash solution and then acidifying with hydrochloric acid. The 
urine will turn a beautiful green color if the bile-pigments be 
present. 

Indoxyl-sulphuric Acid. 

Indoxyl-sulphuric acid (C 8 H 7 XS0 4 ), also called urine in- 
dican, and formerly known as uroxanthin, occurs in normal urine 
as an alkali salt, whose properties have been fully considered in 
Section II Indoxyl-sulphuric acid is derived from indole, which 
is first oxidized in the system into indoxyl and then is united 
with sulphuric acid. Indole is formed by the putrefaction of 
proteids. and hence the quantity excreted by the kidne3~s is 
greater upon a meat than upon a vegetable diet. 

Clinical Significance, — Variations in the quantity of so-called 
indican in the urine occur within comparatively narrow range in 
health ; but in certain pathological conditions the increase be- 
comes very marked. Clinically, therefore, an increased excretion 
of this substance by the kidneys is observed in Addison's dis- 
ease, cholera, carcinoma of the liver, chronic phthisis, central 
and peripheral diseases of the nervous system, typhoid fever, 
d} T sentery, acute general peritonitis, multiple fymphoma, fetid 



ABNORMAL CONSTITUENTS OF URINE. 133 

bronchitis, ichorous pleural exudations, diabetes mellitus, as well 
as in a number of others. 

In obstructive diseases of the small intestine its excretion 
is sometimes enormously increased, owing probably to the favor- 
able conditions for the absorption of indole. The simple ob- 
struction of the colon does not cause its increase in the urine. 
Obstruction of the large intestine, only when it causes consider- 
able disturbance in the motion of the contents of the upper 
ileum, gives rise to its increased excretion by the kidneys. 

In general, it has been considered that the appearance of large 
quantities of so-called indican in the urine implies that an abun- 
dant albuminous putrefaction is progressing in some part of the 
system. Thus, in pleurisy it indicates a copious, unhealthy exu- 
dation, and in peritonitis it may be taken as an evidence of the 
formation of unhealthy pus. The putrefaction of secretions rich 
in albumin in the intestines explains its increase in the urine 
during starvation. 

Detection of Urine Indican. — Jaffe's method consists in mixing 
10 cubic centimetres of strong hydrochloric acid with an equal 
volume of urine in a test-tube, and, while shaking, add drop by 
drop a perfectly fresh, saturated solution of chloride of lime, or 
chlorine-water, until the deepest obtainable blue color is reached. 
The mixture may next be titrated with chloroform, which readily 
takes up the indican and holds it in solution, and the quantity 
present may be approximately estimated according to the depth 
of the color. If the urine contain albumin it should be removed 
before applying this test, otherwise the blue color, often arising 
from the mixture of liydrochloric acid and albumin after standing, 
may prove misleading. 

2. Mac Murines Method. — (a) Equal parts of urine and lrydro- 
chloric acid with a few drops of nitric acid are boiled together, 
cooled, and agitated with chloroform. The chloroform becomes 
violet if much indican be present, and shows an absorption 
band before D, due to indigo blue, and another after D, due to 
indigo red. 

This method is more trustworthy than Jaffe's, because chlo- 
ride of lime destroys small quantities of indigo. 

(6) A rough, approximate method may be employed upon the 



134 ANALYSIS OF URINE. 

foregoing principle, as follows : Pour 4 cubic centimetres of hy- 
drochloric acid into a small flask, and while stirring add from 10 to 
20 drops of urine. If the proportion of indican be about normal 
the resulting color will be rather light-yellow ; if in excess the 
acid will turn violet or blue — the more intense will be the color 
in proportion to the quantity of indican present. If no color- 
ation appear after waiting a minute or two the indican is not in 
excess, however deep a color may subsequently appear. 

If 2 or 3 drops of nitric acid be added to the test, as in the 
original method, it becomes more delicate. (See also page 43.) 

The Diazo Reaction in Urine. 

The diazo test was suggested by Ehrlich, in 1882, as a valu- 
able diagnostic measure in typhoid fever, although he admitted 
the occurrence of this reaction in a few other conditions shortly 
to be considered. 

The diazo reaction depends upon the fact that if sulphanilic 
acid (amidosulphobenzol) be acted upon by HN0 2 , diazosulpho- 
benzol is formed, which unites with certain aromatic substances 
occasionally present in the urine to form aniline colors. 

Dr. Friedenwald has recently reviewed the literature of this 
reaction, 1 and shown that many of the contradictory results 
obtained by some observers are due to failure in canning out 
Ehrlich 's methods in performing the test, which is best accom- 
plished as follows : — 

• To obtain diazosulphobenzol in a perfectly fresh condition, 
sulphanilic acid is kept in solution with hydrochloric acid ; to 
this sodium nitrite is added, whereupon HN0 2 is liberated and 
diazosulphobenzol is formed. 

Process. — Two solutions are prepared, as follows : — 

1. Two grammes of sulphanilic acid ; 50 cubic centimetres of 
Irvdrochloric acid ; 1000 cubic centimetres of distilled water. 

2. A 0.5-per-cent. solution of sodium nitrite. 

In performing the test 50 parts of No. 1 and 1 part of No. 2 

are mixed, and equal parts of this mixture and of the urine in a 

test-tube is rendered strongly alkaline with ammonia. If the 

reaction be positive the solution assumes a carmine-red color, 

1 New York Medical Journal, December 23, 1893. 



ABNORMAL CONSTITUENTS OF URINE. 135 

which on shaking must also appear in the foam. Upon standing 
for twenty-four hours a greenish precipitate is formed. 

The test must not be considered positive unless a distinct red 
coloration extends to and includes the foam on shaking. 

Clinical Significance. — Ehrlich's original claims for the diazo 
reaction were as follow : — 

" 1. The reaction is most commonly found in typhoid fever 
from the fourth to the seventh day and thereafter, and if the 
reaction be absent the diagnosis is doubtful. 

" 2. Cases of typhoid fever characterized by faint reaction and 
occurring only for a short time may be predicted to be of very 
mild type. 

" 3. The reaction is occasionally noted in phthisis pulmonalis, 
but only in cases pursuing a rapid course toward a fatal ter- 
mination. 

" 4. The reaction is sometimes, but not often, observed in 
cases of measles, miliary tuberculosis, pyaemia, scarlet fever, and 
erysipelas. 

" 5. In diseases unaccompanied by fever, as chlorosis, hy- 
dremia, diabetes, diseases of the brain, spinal cord, liver, and 
kidneys, the reaction is always absent." 

The weight of clinical evidence strongly confirms all of 
Ehrlich's original claims for this reaction, but more especially so 
with regard to typhoid feA^er and pulmonary tuberculosis ; if 
present in the latter disease any length of time, the prognosis is 
very unfavorable. 

/3-Oxybutyric Acid (C 4 H 8 3 ). 

This acid forms an odorless syrup which is readily miscible 
with water, alcohol, and ether. It is an optically active sub- 
stance, being, in fact, dextro-rotatory ; so that it interferes with 
the estimation of sugar in the urine by polarimetry. It is non- 
precipitable by lead acetate and amnion iacal basic lead acetate. 
On boiling with water in the presence of a mineral acid, it 
decomposes into OL-crotonic acid — which melts at 72° C. — and 
water. It yields acetone upon oxidation with chromate mixture. 

Clinical Significance. — The appearance of hydroxy butyric 
acid in the urine was first demonstrated bv Minkowski, Kulz, 



136 ANALYSIS OF URINE. 

and Stadelmann. It is usually accompanied by diacetic acid in 
the urine, and sometimes by acetone. It is especially noted in the 
urine in severe or chronic cases of diabetes mellitus. It has 
also been observed in the urine in cases of measles, scurvy, 
scarlet fever, and in diseases of the brain. Aside from these, 
little is at present known of its clinical relations. 

Detection. — 1. If a urine be dextro-rotatoiy after fermenta- 
tion with yeast, it is strongly probable that hydrox}^butyric acid 
is present. 2. Ruiz's method consists in evaporating the fer- 
mented urine to a syrupy consistence, and, after the addition of an 
equal volume of concentrated sulphuric acid, distill directly with- 
out cooling ; au-crotonic acid is produced, which is distilled, and, 
after strongly cooling, the distillate is collected in a glass ; crys- 
tals which melt at -\- 72° C. separate. If no crystals be obtained, 
then shake the distillate with ether and test the melting-point 
with the residue, which has been washed with the water obtained 
after evaporating the ether. 

Ptomaines and Leucomaines. 

The term ptomaine was originally used to designate those 
products of putrefaction which give the reaction of vegetable 
alkaloids and possess more or less poisonous characters. It has 
since been found that similar alkaloids are formed during the 
life of animal organisms ; these are termed leucomaines. Pto- 
maines, or putrefactive bases, are transition products of decom- 
position ; or, in other words, temporary forms through which 
matter is being transformed from the organic to the inorganic 
state by means of the action of bacterial life. They are chem- 
ical compounds of a basic nature, and their deep interest and 
importance in the field of modern medicine may at once be per- 
ceived from the fact that they constitute the chemical factors in 
the causation of all infectious diseases. 

It has been erroneously supposed that all ptomaines are 
highly poisonous; but not onty are many of them inert, but it 
may be stated that the majority of them isolated to date do not 
produce harmful results to the organism in ordinary quantities. 
On the other hand, some of them are highly toxic, and such 
Brieger first proposed to designate as " toxins." 






ABNORMAL CONSTITUENTS OF URINE. 137 

Ptomaines resemble vegetable alkaloids in that they all con- 
tain nitrogen as the chief element of their basic character. Some 
of them also contain oxygen, corresponding to the vegetable 
fixed alkaloids, while those devoid of oxygen correspond to the 
volatile alkaloids. 

Selmi was probably the first — in 1880 — to claim that the basic 
substances formed in the organism during pathological changes 
often appeared in the urine, constituting an index to the patho- 
logical condition of the patient. He demonstrated, in the urine 
of a patient with progressive paralysis, two bases resembling 
nicotine and coneine. Since then Bouchard, Yilliers, Le'pine, 
Gautier, and others have demonstrated the presence of a few 
other basic products in the urine in other diseased conditions. 
It is now well known that the urine in certain diseases, as 
cholera and septicaemia, is decidedly toxic in character. Bouchard 
Chavrin, and Ruffer have proved that bacterial poisons generated 
in the system through disease can be excreted in the urine. 
They produced immunity to the action of the bacillus pyocy- 
aneus upon animals by previous injections of urine of animals 
inoculated with that bacillus as well as with filtered cultures 
thereof. Unfortunately, as yet these investigations have not 
been pushed to sufficient completion to furnish much practical 
data in reference to infectious diseases, since but few bacterial 
ptomaines have yet been isolated from the urine. The impor- 
tance, however, of this comparatively new field of uranalysis 
can scarcely be overestimated, since it is strongly probable that 
careful investigation of the urine in this direction may throw 
important light upon a large class of diseases. 

It only remains here to refer to the few ptomaines which have 
been isolated from the urine, and the methods by which this has 
been accomplished. First, with regard to normal urine, much 
difference of opinion prevails as yet in reference to the presence 
or absence of alkaloidal toxins. When through defective renal 
action the leucomaines become retention products, they at once 
assume immense importance in the chemistry of the urine. The 
researches of Pouchet strongly confirm the presence of toxic 
alkaloids in normal urine; while, on the other hand, Villiers 
denied their existence, claiming that the observed physiological 



138 ANALYSIS OF URINE. 

action is wholly due to the presence of potassium salts. Since 
we know that toxins of an alkaloidal nature (leucomaines) are 
formed in the organism through tissue metabolism, and, further- 
more, that the urine constitutes at least one channel of escape 
for similar compounds, there seems no reason to doubt their 
presence in urine ; at least, in minute quantity. Bouchard, 
Guerin, and Lepine have shown that at least that which has been 
taken for these compounds is greatly increased in the urine in 
pathological states. 

With regard to the isolated ptomaines, Baumann and Udransky separated 
several basic derivatives, amongst them cadaverin, putrescin, and a small 
amount of a third base from the urine of a patient suffering from catarrhal cys- 
titis ; normal urine being found free from these substances. 

Putrescin — C 4 H 12 N 2 — is closely related to cadaverin, since they nearly 
always occur together or alternately from the same source. Brieger obtained it 
from putrefying human viscera after exposure of from three days to three weeks 
at ordinary temperatures. It has been obtained from herring (twelve days' ex- 
posure), from pike (six days' exposure), from haddock (two months' exposure), 
and from decaying mussel (sixteen days' exposure). It is especially abundant 
in cultivations of comma or cholera bacillus, and hence it is believed that sub- 
stances similar to putrescin are the true chemical poisons in cholera. Putrescin 
has been isolated from the urine in cases of cystinuria by several observers since 
Brieger's first discovery. It is toxic to the organism, but its tetra-metbyl deriva- 
tion is incomparably more so, causing symptoms of salivation, dyspnoea, contrac- 
tion of the pupils, muscular paralysis of the limbs and trunk, ejaculation of 
semen, dribbling of urine, and violent convulsions. 

Cadaverin — C5H 14 N., — appears in decomposing tissues usually before the 
occurrence of putrescin. Brieger obtained it from putrefying heart, liver, 
lungs, etc., at ordinary temperatures, in three days' exposure; from putrid 
mussel in sixteen days. Like2Jutrescin, it is a constant product of comma bacil- 
lus upon any soil upon which they may be cultivated. Cadaverin is a constant 
associate — perhaps a product — of the activity of vibriones, since it never occurs 
in cultures in which this genus is absent. It is therefore absent from both nor- 
mal and typhoid stools, as well as from cultures of the bacillus of Emmerich 
and Eberth. Both putrescin and cadaverin may be obtained from the urine of 
cystinuria by precipitation with benzoyl chloride (Baumann's method). 

Trimethylamine — C 3 H 9 N — has been found in human urine. This base occurs 
both in animal and vegetable tissues. It has been obtained from ergot, the blood 
of calves, herring-brine, in the putrefaction of yeast, in cheese, in human liver 
and spleen (two to seven days' exposure), in perch (six days' exposure), in 
cultures of streptococcus pyogenes on broth and blood-serum. It is not a violent 
toxin, large doses being required to markedly disturb the system. 

Beatin — C 5 H 13 N0 3 — is a well-known base, the product of cotton-seed, beet- 
juice, turnip, vetch-seeds, etc. It has been found in the urine by Liebrich. 
This base is of no pathological significance, since it is non-toxic to the organism. 



I 



ABNORMAL CONSTITUENTS OF URINE. 139 

Jaksch, who has studied the subject of basic derivatives of the urine, both 
normal and pathological, finds that, while normal urine and that of some diseases 
hold these substances only in minute quantity, in certain other morbid states 
this amount is very considerable. He makes the following suggestions as a 
guide for investigation in this field of work : — 

In the first place, he suggests that it would be well to follow the example of 
Brieger, Baumann, and Udrasky in withholding the name alkaloids from the 
bodies diamines, which are derived from the system under morbid conditions, 
because all that have been recognized as yet are simply diamines, and do not ex- 
hibit the characteristic property of alkaloids, viz., the pyridin radicle. In the 
second place, it is desirable to discriminate between the physiological bases of 
the urine creatinin, reducin, etc., which belong to normal urine, and those which 
are associated only with certain diseased states. It is not intended to imply by 
this that the physiological bases — leucomaines — cannot under any circumstances 
give rise to diseased or poisonous symptoms. On the contrary, it is highly prob- 
able that retention, and still more the increased formation of such products, 
under certain circumstances may induce very grave symptoms, and even greatly 
imperil the life of the patient. Again, it seems probable that in certain acute 
diseases, specific substances of a toxic nature, not present in normal urine, may 
be excreted with that fluid. 

Jaksch makes the following suggestive classification of the subject : — 

(a) Clinical (morbid) symptoms depending upon retention of the physio- 
logical basis. Under this head would come urgemia and certain of the symptoms 
of obstruction — retention toxicosis. 

(6) Clinical symptoms referable to the presence of basic products which are 
found in the system (blood, etc.) in disease and eliminated with the urine — noso- 
toxicosis. 

(c) Clinical symptoms which are caused by the formation of toxic basic sub- 
stances from morbid matter, such as pathological fluids lodged in certain parts 
of the organism. Such bases being absorbed give rise to symptoms of severe 
poisoning. Under this head would come the collective symptoms of ammo- 
niaemia, and others which follow the absorption of gangrenous pus — auto-toxicosis. 

(d) Clinical symptoms, and consequently morbid types induced by the action 
of toxic bases taken into the system with the food, such as the poison of sausages, 
cheese, canned fruits, etc., etc. — exogenic toxicosis. 

Detection. — A number of methods are in use for the detection and isolation 
of these bases, the more prominent of which are those of Dragendorf, Stas-Otto, 
Brieger, Gautier, and Etard. Since all of these methods are somewhat difficult 
and tedious, only the most suitable methods for uranalysis will here be described. 
For such purposes Brieger's method serves best ; but in some cases it is important 
that the urine be first concentrated in vacuo. Sufficient hydrochloric acid is first 
added to render the urine acid, and the mixture is then boiled for a few minutes 
and filtered. The filtrate is concentrated at first over a flame, and subsequently 
over a water-bath, to a syrupy consistence. 

In consequence of the instability of the bodies sought, it is advisable to 
evaporate in vacuum and at the lowest possible temperature, more especially so 
if the urine be foul. 

The thick fluid is next mixed with 96-per-cent. alcohol, filtered, and the 



140 ANALYSIS OF URINE. 

filtrate treated with a warm alcoholic solution of lead acetate. The resulting lead 
precipitate is removed by filtration and the filtrate concentrated — preferably in 
vacuo — to a syrup, and again taken up in 96-per-cent. alcohol. The alcohol is 
next evaporated, and the residue, dissolved in water, is freed from lead by the 
addition of sulphuretted hydrogen and filtration. The filtrate is acidified with 
hydrochloric acid and evaporated to a syrupy consistence. It is then diluted 
with alcohol, and alcoholic solution of mercuric chloride is added. The resulting 
precipitate is boiled in water, and certain ptomaines may separate at this stage 
in consequence of different solubilities of the double salts of mercury. The better 
to secure this, the precipitate may be treated successively with water at various 
temperatures. Should it be thought that the lead precipitate may have retained 
some of the ptomaines, it may be suspended in water, the lead converted into 
sulphide, and the fluid treated in the manner just described. 

The solution obtained as above is filtered, freed from mercury, and evapo- 
rated ; the excess of hydrochloric acid is carefully neutralized with sodium 
carbonate (the reaction is kept feebly acid), then it is again extracted with 
alcohol to free it from inorganic salts. The alcohol is evaporated, the residue 
dissolved in water, the remaining traces of hydrochloric acid neutralized with 
sodium, the whole acidified with nitric acid and treated with phosphomolybdic 
acid. The phosphomolybdate double compound is separated by filtration and 
decomposed by neutral lead acetate or, more readily, by heating over a water- 
bath. The lead is next removed by means of sulphuretted hydrogen (hydrogen 
sulphide) ; the filtrate is evaporated to a syrupy consistence and taken up with 
alcohol. Several ptomaines are thus separated as hydrochlorates, and may be 
obtained in the form of double salts of gold, or platinic chloride, and of picric 
acid. The chloride of the base is obtained by removing the metallic base by 
precipitation with sulphuretted hydrogen, while the picrate is taken up with 
water, acidified with hydrochloric acid, and repeatedly extracted with ether 
to remove the picric acid. The last step is to ascertain if any ptomaines remain 
in the phosphomolybdic-acid filtrate after precipitation of the phosphomolybdic 
acid. 

Brieger has obtained some of his ptomaines by a simpler modification of his 
above complete method. Thus he has obtained neurodin by treating the aque- 
ous extract of the organic matter, after boiling and filtration, with mercuric 
chloride, collecting the precipitate, decomposing it with sulphuretted hydrogen, 
evaporating the filtrate over a water-bath, and extracting the base with alcohol. 

Properties of Animal Bases. — 1. They all have an alkaline 
reaction. 

2. They are insoluble in water; soluble in acids forming 
compounds ; precipitated from such compounds by ammonia. 

3. Iodine and potassium iodide give a brown, flocculent 
precipitate. 

4. Potassio-mercuric-iodide solution produces flocculent, 
yellowish-white precipitates, insoluble in acids and dilute alka- 
lies, easily soluble in alcohol, and generally, also, in ether. 



ABNORMAL CONSTITUENTS OF URINE. 141 

5. Iodide of bismuth and potassium give orange precipitates 
in solution acidulated with dilute sulphuric acid. 

6. Phosphomolybdic acid gives a bright or brownish-yellow 
precipitate, insoluble in water and dilute mineral acids. 

7. Metatungstic and phosphotungstic acids give a white, 
flocculent precipitate, with difficulty soluble in water and dilute 
acids. 

8. Tannin in neutral or feebly-acid solutions give yellow or 
white precipitates with most ptomaines. 

9. Chloride of gold gives a yellow or yellowish-white precipi- 
tate, either amorphous or crystalline. 

10. They are all oxidizable and unstable, especially under the 
influence of an excess of mineral acid, which colors them red and 
then converts them into a resinous mass. 

11. Picric acid precipitates most of them, the color of the 
precipitate usually being pale yellow. 

12. The animal bases are energetic reducing agents, decompos- 
ing chromic acid, iodic acid, and silver nitrate. With potassium 
ferrocyanide and ferric chloride they give Prussian blue. This 
was formerly considered to be characteristic of the animal alka- 
loids, but it is now known that many vegetable alkaloids give 
the same reaction, and a few of the animal alkaloids (especially 
those containing oxygen) do not give it. As yet there is no 
known class reaction b} r which the animal bases can be separated 
from those of vegetable origin. 

THE URINE AS A TOXIN. 

It has long been generally believed that normal urine is an 
auto-intoxicant. The well-known fact that suppression of the 
urine is invariably followed by certain uniform toxic symptoms 
ending in death seemed to leave no further proof of the truth of 
this belief necessary. It was not, however, until a comparatively 
recent period (1881) that Feltz and Ritter first demonstrated the 
actual toxicity of normal urine by injecting it into the blood of 
animals, thereby invariably invoking symptoms which were fol- 
lowed by death of the animals when the dose approached a certain 
relative amount. These experiments were soon after repeated and 
confirmed by Bocchi, Schiffer, and others. Two or three years 



142 ANALYSIS OF URINE. 

later Dupard, Lepine, and Gruerin established the special toxicity 
of certain pathological urines which has since been confirmed by 
numerous observers. 

Following the researches of Feltz and Bitter, Bouchard 
commenced the investigation of the toxicity of normal urine, and 
very recently Lenoir gives a complete review of this subject, as 
does Charrin. The method of investigation pursued by Bou- 
chard 1 consisted of intra-venous injections of urine in animals 
(chiefly rabbits), and the results would seem to have established 
the following conclusions : — 

1. That the toxic power of normal urine as a whole is such that 
an average of 45 cubic centimetres of urine kills 1 kilogramme of 
living animal ; and, therefore, the urine of two days and four 
hours contains sufficient toxic matters to kill a man of 60 kilo- 
grammes weight. 

2. The toxic symptoms induced by intra-venous injections of 
urine are as follow : (a) Myosis ; contraction of the pupils begin- 
ning with the injection of 10 cubic centimetres to 15 cubic centi- 
metres of urine per kilogramme ; the pupils contracting to pin- 
hole size, and thus remain until after death, after which they 
sometimes dilate, (b) The respirations become hastened and of 
diminished range, (c) Somnolence and coma follow, (d) Diu- 
resis becomes marked, micturition occurring every two or three 
minutes, (e) Marked lowering of temperature succeeds. (/) Di- 
minished palpebral and corneal reflexes are present, (g) Death 
succeeds in coma or convulsions, (h) The heart continues to 
beat for some time after death. 

3. The toxicity of the urine varies with certain circumstances, 
viz. : (a) The urine is twice more toxic during the day than 
during the night, (b) The night urine is strongly convulsive 
and but feebly narcotic, while the day urine is the reverse, — 
strongly narcotic, but feebly convulsive, (c) Active muscular 
exertion in the open air diminishes the toxic power of the urine 
one-third, and this diminution of toxicity continues for from 
twenty-four to forty-eight hours after cessation of the exercise. 

4. The toxicity of the urine is not due to urea, uric acid, or 

1 Auto-Intoxication in Disease, Ch. Bouchard. Translated by T. Oliver. 
Published by The F. A. Davis Co., Philadelphia, 1894. 



ABNORMAL CONSTITUENTS OF URINE. 143 

creatinin, since the injection of these substances into the blood 
in much larger proportional amounts than those in which they 
exist in normal urine proves non-toxic. 

5. The toxicity of urine increases by permitting it to stand 
some time, as well as by increasing its temperature, even though 
fermentation be prevented. By this means a urine that ordi- 
narily kills by coma becomes not only more toxic, — killing in 
smaller doses, — it also causes convulsions instead of coma. 

6. The following facts are brought out regarding the isolation 
of the toxic elements of the urine : (a) If the urine be decolor- 
ized by charcoal it deprives it of about one-third (33 per cent.) 
of its toxic powers. (6) An aqueous extract of the urine 
(containing chiefly the mineral elements) causes contraction of 
the pupils, convulsions, and lowered temperature, but no coma, 
diuresis, or salivation, (c) An alcoholic extract of the urine 
produces somnolence, deep coma, and diuresis ; but it does not 
cause contraction of the pupils or convulsions. 

T. In acute uraemia the urine becomes non-toxic, and it may 
be injected into the blood in quantity equal to that of water 
(about 90 to 120 cubic centimetres per kilogramme) before it 
proves lethal, and then only mechanically, by interfering with 
the normal osmosis. 

It will be seen, from these investigations, that normal urine 
owes its toxic properties not to any one, but to several constitu- 
ents ; and although Bouchard has not succeeded in completely 
isolating these, yet his results are suggestive in that direction. 
Briefly stated, his results are as follow : At least seven toxic 
agents are present in normal urine: — 

1. A diuretic substance, which is fixed and of organic nature, 
non-removable by filtration through carbon, but is soluble in 
alcohol. This substance answers to all the features of urea, and 
is only toxic in enormous doses. 

2. A narcotic substance, also fixed and of organic nature, 
non-removable by carbon, and soluble in alcohol. It is not 
urea, since it does not induce diuresis ; but, on the other hand, 
it causes narcosis. 

3. A sialogenous substance which produces salivation. It 
is only present in small amount in normal urine, and hence its 



144 ANALYSIS OF URINE. 

effects are imobservable in quantities of urine sufficient to kill 
from other contained toxic agents. This substance is stable, of 
organic nature, non-removable by carbon, and soluble in alcohol. 

4. Two substances capable of causing convulsions : (a) One, 
fixed, stable, of organic nature, is both retained and destroyed 
by carbon, and is insoluble in alcohol. It is doubtless an alka- 
loid, and is present during the day in less amount than the nar- 
cotic substance, and also of less physiological activity than the 
latter, (b) A substance which causes myosis; it is fixed, organic, 
and removable by carbon. It is probably a coloring substance 
of normal urine. 

5. A substance which reduces body-heat. It is fixed, of or- 
ganic nature, and insoluble in alcohol. It may also be a urinary 
pigment. 

6. Another convulsive substance of mineral nature, which is 
doubtless potassium. 

Pathological Urine. — In pathological conditions the toxicity 
of the urine may become diminished, or it may become greatly 
increased. As a rule, in acute infectious diseases and fevers, if 
the kidneys remain unaltered, the urine becomes more powerfully 
toxic than in health. On the other hand, in pathological states 
of the kidneys themselves, the toxic powers of the urine become 
more or less diminished, according to the degree of functional 
incapacity of the kidneys. Thus, in acute nephritis or extensive 
chronic changes which greatly cripple the functional capacity of 
the kidneys, the urine may become almost non-toxic. As the 
condition of the kidneys improves the urine becomes more and 
more toxic, and this fact may be taken advantage of as a prog- 
nostic indication in treatment. For instance, if it require 80 
cubic centimetres of urine to kill a rabbit of 1 kilogramme weight, 
it may be assumed that the capacity of the kidneys is crippled 
about one-half (50 per cent.). If in a week later 60 cubic centi- 
metres of urine kill a rabbit of 1 kilogramme weight, it furnishes 
substantial evidence that the condition of the kidneys is much 
improved. 

It has already been stated that the urine in acute uraemia is 
non-toxic. Under such circumstances the kidneys can no longer 
eliminate the usual toxic agents from the system, and the organ- 



ABNORMAL CONSTITUENTS OF URINE. 145 

ism becomes poisoned — uraemic — and all the phenomena described 
as due to intra-venous injections of urine are evoked. 

Our present knowledge of this subject warrants tbe statement 
that the healthy organism is only saved from lethal auto-intoxi- 
cation by the liver and kidneys ; the former destroys the larger 
proportion of the systemic toxins, and those not so destroyed 
are eliminated chiefly by the kidneys, if the latter be healthy. 

In a large proportion of pathological urines (the kidneys re- 
maining sound) the normal toxicity of the urine becomes in- 
creased, and, moreover, new toxic properties are developed, 
notably those with convulsive powers. Thus, in tetanus the 
urine is powerfully toxic, and if injected into the circulation it 
evokes most of the tetanic phenomena. M. Labbe injected the 
urine of a tetanic patient into the circulation of an animal, with 
the following results : After the sixth cubic centimetre (per kilo- 
gramme) mild tremors occurred ; the pupils became punctiform 
at 10 cubic centimetres. From 12 cubic centimetres violent 
tonic spasms with convulsions occurred up to 34 cubic centi- 
metres. At the latter point death occurred from opisthotonos. 

The urine in pneumonia is strongly toxic, the symptoms 
being nearly as pronouncedly convulsive as in the case of tetanus. 
The urine in pneumonia proves lethal in from 19 cubic centi- 
metres to 38 cubic centimetres per kilogramme. In typhoid 
fever, on the other hand, Bouchard has observed that the urine 
produces only the toxic symptoms of normal urine ; death occurs 
at from 50 to TO cubic centimetres per kilogramme with only 
slight myosis, coma being present, but not convulsions. In leu- 
cocythdemia the urine is highly toxic, causing convulsions and 
death at 15 to 20 cubic centimetres per kilogramme. 

The urine possesses special and marked toxic powers in 
cholera. Thus, cyanosis is only produced by choleraic urine ; 
muscular cramps follow, unlike the convulsions produced by 
other urines, since the spasms begin long after the beginning 
of the injections, and they continue long after the injections are 
discontinued. Cooling of the body is more pronounced than 
from injections of any other urine. Albuminuria appears at 
once and in marked degree, while with normal urine albuminuria 
is rare and only occurs late. Diarrhoea always follows injections 



146 ANALYSIS OF URINE. 

of choleraic urine ; the stools become pale, watery, and devoid of 
bile. The albuminuria increases until complete anuria occurs, in 
about thirty-six hours, and death soon after occurs with a rectal 
temperature of 33° or 34° C. 



SECTION VI. 

URINARY SEDIMENTS. 

Urinary sediments are most conveniently classified, for pur- 
poses of study, into two divisions, viz., chemical substances and 
anatomical substances. 

Chemical sediments, with but few exceptions, exist in the 
form of solution in normal urine, and their appearance as crys- 
talline, amorphous, or other form of sediments may result from 
excessive formation or excessive excretion, or alterations in the 
urine affecting its solvent powers. The chief chemical deposits 
met with in the urine are uric acid, the urates, calcium oxalate, 
cystin, leucin, tyrosin, xanthin, and phosphates. 

The anatomical sediments are in most cases foreign sub- 
stances, and therefore do not exist in normal urine. They consist 
of such structures as pus-corpuscles, blood, renal casts, sperma- 
tozoa, fragments of growths, fungi, infusoria, etc. The ana- 
tomical elements found in the urine are more or less insoluble, 
and, therefore, when the urine stands they fall to the bottom as 
sediments. 

Our methods of examining urinary sediments are both chem- 
ical and microscopical. Thus, the chemical deposits may often 
be recognized by their characteristic reactions ; or the micro- 
scope may be employed to determine the characteristic form of 
the deposit when crystalline, which is often of itself diagnostic. 
In determining the character of the anatomical deposits the 
microscope constitutes the chief resource, although, in some 
cases, chemistry materially aids the investigation. 

Sedimentation op Urine. 
The older method of obtaining urinary sediments for investi- 
gation consisted in letting the urine stand in conical vessels for 
twenty-four hours or so, when the sediment would usually be 
found collected in the bottom of the vessel. Much difficult}' was 
formerly encountered by this method in securing sediments for 

(147) 



148 ANALYSIS OF URINE. 

examination which remained unchanged, since the length of time 
necessary to secure the deposit almost necessarily involved alter- 
ations in the urine at ordinary temperatures. Of late years this 
has been in a measure overcome by the addition of preservative 
agents to the urine, such as chloral hydrate, salicylic acid, 
resorcin, etc. These, however, all interfere with the chemical 
examination of the urine, more especially in making examina- 
tions for sugar and urea. But the most serious objection to the 
old method was the necessit}^ of waiting for several hours before 
a satisfactory microscopical examination of the urine could be 
made. 

More recent experience has demonstrated the immense ad- 
vantages of the centrifugal method of obtaining urinary sedi- 
ments for purposes of microscopical examination. The principle 
of this method depends upon the fact that when the urine is 
placed in tubes and revolved upon horizontal rotating arms at a 
high speed, a centrifugal force is exerted upon all solid particles 
in the urine hundreds of times greater than gravity ; and, conse- 
quently, the urinary sediment is deposited in the bottom of the 
tubes almost immediately, irrespective of the specific gravity of 
the urine or the character of the sediment. Some of the advan- 
tages of this method are as follow : — 

1. Centrifugal sedimentation of the urine permits of an im- 
mediate microscopical examination, instead of waiting for from 
twelve to twenty-four hours ,by the old method of gravity. 

2. The centrifugal method secures more complete and concen- 
trated sedimentation, and therefore it is better suited for pur- 
poses of microscopical diagnosis. 

3. Microscopical examination may be made of freshly-voided 
urine before casts or morphological elements have had time to 
undergo maceration or solution in the urine, and before bacterial 
fermentation occurs, which always greatly obscures the micro- 
scopical field. 

4. It affords the only positive means of distinguishing between 
normal and abnormal crystalline sediments in the urine, because 
by the centrifugal method only can the urine be examined by the 
microscope as soon as voided, and, therefore, before the crystals 
form which are deposited in all normal urines after standing. 



I 



PRECIPITATION OF URINARY SEDIMENTS. 



149 



5. By the old method of gravity it sometimes happened, with 
urines of high specific gravity, that the lighter casts (such as 
those of the narrow, Iryaline order) failed to settle, and thus 
eluded detection. The centrifuge precipitates all casts without 
delay, irrespective of the above-named conditions. 

6. In consequence of the greater concentration of the urinary 
sediment by the centrifuge, bacterial search is rendered more 
simple and successful; micro-organisms, such as tubercle bacilli, 
being found with greater ease and certainty. 




Fig. 12.— The Author's Electric Centrifuge. (One-fourth actual size.) 



It will therefore be readily seen that the centrifuge is destined 
to rapidly supersede the old method of gravity for all purposes 
of urinary sedimentation. 

Various forms of the centrifuge are manufactured for urinary 
purposes, and may be obtained of the leading instrument dealers. 
At present, the best hand-power centrifuge for urinary purposes 
is made by K. Jung, of Heidelberg. For practical work, the 
centrifuge should be capable of a speed of at least 1000 revolu- 
tions per minute. The accompanying cut (Fig. 12) shows the 



150 ANALYSIS OF URINE. 

electric centrifuge especially designed by the author for urinary 
work. 

By means of this apparatus, renal casts, epithelium, pus, 
blood, bacteria, c^stals, etc., and, in short, all urinary sediments, 
— organic and inorganic, — can be sedimented at once, thus 
affording an immediate microscopical examination where for- 
merly it required hours or even days to obtain the same results 
b}' the old method of gravity. 1 

The author's electric centrifuge is capable of a maximum 
speed, without tubes, of over 6000 revolutions per minute, by 
multiple registers on the 110-volt current; with small, light 
sediment tubes, it is capable of a speed of from 2500 to 3500 
revolutions per minute; with large tubes (carrying one ounce 
of urine) it attains a speed of 1500 to 2000 revolutions per 
minute. The precipitating centrifugal force exerted by this 
centrifuge is 2000 times greater than gravity, and, therefore, a 
sediment requiring twenty-four hours to precipitate by gravity 
ma}^ be obtained by this centrifuge in less time than two minutes. 
In throwing down sediments for purely microscopical purposes, 
the best grade of speed, as a rule, is 1200 to 1500 revolutions, 
although higher speed may be employed if desired. In other 
words, the author finds for this purpose that medium speed and 
proportionate increase of time give the best results. Bacterial 
search forms an exception to this rule, high rates of speed in 
such cases being preferable. 

The author's electric centrifuge, by reason of its special de- 
sign and construction, the field and armature of the motor being 
specially wound, can be operated by currents of 110 volts direct 
(with resisters) or 52 volts alternating. It therefore possesses the 
unusual advantages of operating by either direct or alternating 
currents without overheating. It may hence be operated by 
the currents of any of the existing sj^stems of electro-incandes- 
cent lighting. It can also be operated by either the ordinary 

1 By means of percentage tubes and special methods devised by the author 
(see Section II, page 64), quantitative percentage determinations may be made by 
this centrifuge of chlorides, phosphates, sulphates, albumin, pus, etc., and this 
method will be extended to include as many of the constituents of the urine, 
normal and abnormal, as will be found practicable and advantageous. 



I 



PRECIPITATION OF URINARY SEDIMENTS. 



151 



galvanic or storage currents. This centrifuge is armed with 
aluminium shields for the glass sediment tubes, which prevent 
all danger from breakage of the latter 
at the highest attainable speed. At- 
tachment-plugs, resisters, aluminium 
shields, sediment and percentage tubes, 
and all accessories are furnished by the 
manufacturers. 1 The cost of the whole 
apparatus, with the accessories neces- 
sary for sedimentation for microscopi- 
cal purposes, as well as for percentage 
centrifugal analysis of urine, is only a 
trifle more than that of the hand-power 
centrifuge made by R. Jung, of Heidel- 
berg. 

It may be stated, in conclusion, 
that the immense convenience and 
saving of time effected by centrifugal 
methods, as applied to uranalysis, can 
only be fully appreciated by those who 
have employed them. By the aid of the 
electric centrifuge, complete qualita- 
tive and quantitative examinations of 
the urine, including microscopical 
search, are daity made in the author's 
laboratory within twenty minutes. 

From a somewhat extensive experi- 
ence in the use of the centrifuge in 
urinary work, the author finds that the 
old form of bulb-tipped sediment tube 
is very unsatisfactory where the amount 
of sediment is small : the sudden stop- 
page of the centrifuge creates currents 
in the bulb that often dislodges the 
sediment and causes it to rise in the tubes. The new form of 
sediment tubes (Fig. 13), devised by the author for his electric 

1 The author's centrifuge is manufactured and supplied by Win. F. Duha, 
manufacturer of electric specialties, Nos. 18 and 30 W. Randolph Street, Chicago. 



Fig. 13.— The Author's 
Sediment Tubes for Cen- 
trifugal. Sedimentation. 
(Full size.) 



152 ANALYSTS OF URINE. 

centrifuge, completely obviates this difficulty; in fact, the urine 
may even be decanted and the sediment will remain in the 
bottom of the tubes. The author has recently devised an extra 
arm for his centrifuge to cany special tubes for bacteriological 
work. The haematokrite tubes for measuring blood-corpuscles 
may also be used with this arm. The speed attainable by this 
appliance with the author's electric centrifuge is enormous, — 10 
to 15 thousand revolutions per minute. 

In searching for urinary deposits it is of prime importance 
to deal with a freshly-voided sample of urine. As already noted, 
the urine is a very unstable fluid, and at ordinary temperatures 
chemical alterations very soon occur, which may dissolve or so 
alter either the chemical or anatomical deposits as to render them 
altogether difficult or even impossible of recognition. Moreover, 
in consequence of these changes, a series of deposits occur in all 
normal urines, upon long standing, with which it is well to 
become familiar. 

Strictly normal urine of acid reaction, when freshly voided, 
is transparent and free from sediment. After standing some 
time, there forms, in the lower third of the volume of urine, the 
" nubecula" — a slight haze, consisting of mucus, carrying with it 
a few mucous corpuscles and flat epithelia, thrown off chiefly from 
the bladder-walls. The nubecula may be most readily seen by 
holding the urine up to a good light with a dark but narrow 
background intervening ; or it may be quickly precipitated by 
the centrifuge, when it will be found to consist of mucus 
entangling epithelial cells and a few mucous corpuscles. Upon 
longer standing, strictly-normaF urine of acid reaction gradually 
deposits {first) a reddish-yellow or clay-colored sediment of 
amorphous urates of potassium, sodium, and ammonium, and 
occasionally of calcium and magnesium, which are readily soluble 
by heat ; {second) and, some time later, the above-described sedi- 
ment is more or less replaced by beautiful, brick-red or dark- 
brown, sharply-outlined crystals of uric acid ; {third) at the same 
time, or later still, there forms among the uric-acid c^stals, or 
are replaced by them, octahedral or envelope-shaped, highly- 
refracting crystals of calcium oxalate; {fourth) and at a still 
later, though variable, period, strictly normal urine deposits a 



PRECIPITATION OF URINARY SEDIMENTS. 153 

sediment composed of the phosphates of the alkaline earths, — 
granular, amorphous calcium phosphate and triangular, prismatic 
crystals of triple phosphate of ammonium and magnesium, often 
interspersed by dark spherules of ammonium urate with attached, 
sharp spicula. 

Again, in strictly-normal urine of alkaline reaction, such as 
frequently occurs in the morning, or three or four hours after a 
meal, there frequently deposits a whitish, flocculent sediment, of 
considerable bulk, consisting of the granular, earthy phosphates. 
These may be made to quickly disappear by destroying the al- 
kalinity of the urine by means of a few drops of any strong acid. 

The explanation of these changes has already been made in 
Section I, page 5. The importance of procuring fresh urine for 
sedimentary investigation will therefore be seen at once, since 
nearly every inorganic and many organic substances in normal 
urine are liable to be deposited upon long standing, when such 
deposits are neither evidences of excess of the deposited sub- 
stances nor of existing pathological conditions. 

When insoluble substances in the urine remain in suspension, 
they produce more or less turbidity ; but when they subside to 
the bottom, they constitute a deposit. Precipitation occurs with 
varying degrees of facility in different urines, both by standing 
and by centrifugation, but less so by the latter, depending in 
part upon the consistence and density of the urine, and in part 
upon the nature of the sediment. Thus, precipitation is more 
rapid in watery urines — as in hysteria and diabetes insipidus — 
than in thick, albuminous, or saccharine urines. Again, the 
heavier crystalline deposits, such as uric acid, the urates and 
oxalates, precipitate rapidly ; while such substances as epithelium, 
pus-corpuscles, and hyaline casts deposit very slowly. In tuber- 
culous conditions of the urinary organs much of the insoluble 
products of ulceration remain more or less permanently sus- 
pended in the urine upon standing, — only the more solid and 
heavier products being precipitated, — and this is considered, in 
a measure, diagnostic of tuberculous urine. 



154 ANALYSIS OF URINE. 

CHEMICAL SEDIMENTS. 

LlTHURIA. 

Uric-acid crystals occur as a sediment rarely, if ever, in other 
than sharply-acid urine. They differ from all other urinary de- 
posits in possessing a deep-yellow or orange-red color ; they may 
at times be pale yellow, but are never colorless. The crystalline 
nature of this deposit may usually be detected readily by the 
naked e3 r e. The essential or primary form of the uric-acid crystal 
is that of rhombic prism, and the great variety in which it is 
found all constitute combinations or modifications of this form. 
Thus, the angles may be nearly equal, forming quadrangular 
plates, or sometimes nearly cubes may be seen. Again, they 
may be seen with rounded ends, forming ovoids or circles. Elon- 
gated crystals are sometimes observed, and these frequently join 
at one end, forming stars. The beauty and variety of these star- 
shaped clusters are very marked. (See Plate Y.) Sometimes 
fan-shaped forms are produced by elongation of the crystals in 
one direction only, instead of the star form. The rough and 
pointed forms of uric-acid crystals are claimed by Ultzmann to 
be of diagnostic significance, being " almost always an accom- 
paniment of renal calculi." For properties and tests of uric acid, 
see Section II, pages 30 to 36. 

Uric acid possesses a strong tendency to crystallize upon 
contact with any solid substance, organic or inorganic. This 
may be observed by its behavior in a vessel upon standing, when 
it will often be noted that the crystals cling to the sides of the 
glass or to threads or specks suspended in the urine. This ten- 
dency renders it more liable than any other crystalline deposit 
to form around some nucleus in the urinary channels, and ulti- 
mately form gravel. This is one of the reasons why nearly 70 
per cent, of the stones found in the bladder are of the uric-acid 
variety. 

The deposit of uric-acid crystals can only be regarded as of 
pathological import when the deposit occurs shortly after the 
urine is voided, — say, within four to six hours. It has already 
been shown that perfectly healthy urine usually deposits uric- 
acid crj^stals after standing ten or more hours. But, on the 



PLATE V. 




Uric Acid Crystals with Amorphous Urates. 
(After Peyer.) 



CHEMICAL SEDIMENTS. 155 

other hand, if uric acid be precipitated from the urine shortly 
after it cools, it very justly forms the foundation for fear that 
the same may occur before it be voided, and thus give rise to 
the formation of calculi and gravel, with the long train of painful 
sy mptoms entailed by such conditions. Before speaking of the 
pathological conditions which usually attend deposits of uric 
acid, it may be well to allude to the conditions of the urine 
which favor such deposits. 

Sir William Roberts, who has carefully investigated this 
subject recently, 1 makes the following interesting observations : — 

" The presence of uric acid in human urine is somewhat anom- 
alous, as it is not needed as a vehicle for the elimination of 
nitrogen. Its place is taken by urea, which, by its easy solu- 
bility, is better adapted to the liquid urine of animals. Perhaps 
uric acid is a vestigial remnant in mammalian descent. But, 
although physiologically insignificant, uric acid is pathologically 
the most prominent component of the urine, chiefly because of 
its tendency to form concretions. 

"All acid urines tend inevitably to deposit their uric acid 
sooner or later. The time of onset of precipitation varies from 
a few hours to five or six days, or even longer. The inference 
from this is that pathological gravel is due to an exaggeration 
of conditions which exist in a less pronounced degree in health. 
To get at an explanation of this spontaneous precipitation it is 
necessary to examine the states of combination of uric acid in 
the urine. 

" Uric acid (C 5 H 4 N 4 3 =H 2 U) is a bibasic acid, and forms 
two regular orders of salts, namely, neutral or normal urates 
(M 2 tJ) and acid urates or biurates (MHTJ) 2 . But, in addition 
to these, it forms a series of hyperacid combinations, first discov- 
ered by Bence Jones, and termed by him quadrurates (MHU.H 2 tJ). 
The neutral urates are never found in the animal body, and are 
only known as laboratory products. The biurates are only 
encountered pathologically as gouty concretions. The quad- 
rurates, on the other hand, are especially the salts of uric acid. 
They constitute the exclusive combination in which uric acid 

1 Proceedings of the Medico-Chirurgical Society, 1890, p. 85. 



156 ANALYSIS OF URINE. 

exists in solution in normal urine, and they become visible some- 
times as the amorphous urate sediment. The urinary excretion 
of birds and reptiles is composed exclusively of quadrurates. 
The special and characteristic reaction of quadrurates is that 
they are immediately decomposed by water into free uric acid 
and biurates. They exist in acid urine in the presence of water 
and of superphosphates. These conditions necessarily involve 
the ultimate liberation and precipitation of uric acid. The first 
step is the breaking up of the quadrurate by the water of the 
urine into free uric acid and biurate, according to the following 
equation : — 

(MHIJ.H 2 tt) + H 2 = (H 2 tJ) -f (MHtT). 

Quadrurate. Free uric acid. Biurate. 

" This explains the liberation of half the uric acid. But the 
biurate thus formed is forthwith changed in the presence of 
superphosphates into quadrurates. Thus : — 

2(MHU) + (MH 2 P0 4 ) =(MHU.H 2 U) + (M 2 HP0 4 ) 

Biurate. Superphosphate. Quadrurate. Diuietallic phosphate. 

By these alternating reactions all the uric acid is at length set 
free. 1 

" Seeing that uric acid exists in acid urine (that is, for some 
sixteen hours out of the twenty-four), amid conditions which, 
if the quadrurates stood alone and uncontrolled, would lead to its 
immediate precipitation, and yet that in the normal course no 
such early precipitation occurs, it is obvious that the urine must 
contain certain ingredients which inhibit or greatly retard its 
water from breaking up the quadrurates. These inhibitory in- 
gredients consist chiefly of (1) the mineral salts and (2) the 
pigments of the urine. The conditions of the urine which tend 
to accelerate the precipitation of uric acid, as in the formation 
of concretions and deposits, are (1) high acidity, (2) poverty in 
mineral salts, (3) low pigmentation, and (4) high percentage of 
uric acid. The converse conditions tend to retard precipitation. 
On the interaction of these factors the occurrence or non- 
occurrence of uric-acid precipitation appears to depend, and 

1 In these formulae the symbol M represents a monad metal, and the symbol 
U the radicle C 5 H 2 N 4 3 . 



CHEMICAL SEDIMENTS. 157 

probably the most important of these factors is the grade of 
acidity." 

Clinical Significance. — Uric-acid sediments are perhaps most 
often encountered in acute fevers and inflammations attended by 
pronounced elevation of temperature. In such cases there is 
diminution of the aqueous elements of the urine, entailing in- 
creased acidity. As a consequence of increased tissue meta- 
bolism, there is also absolute increase of uric acid, as of most 
other urinary solids. In the so-called uric-acid diathesis there 
is often an habitual and pronounced deposit of uric-acid crystals 
in the urine. The causes of this state are partly defective 
physiological action of the liver, and partly errors in diet, 
coupled with sedentary habits of life ; and it is often accom- 
panied by headache, emaciation, and hypochondriasis. Since 
this condition is induced by faulty habits of living which entail 
overwork of the liver, with defective supply of oxygen, it in 
nowise merits the name of " diathesis." 

In the early stages of interstitial nephritis, uric-acid deposits 
are often to be observed ; indeed, the urine frequently throws 
down this deposit habitually for some time before the interstitial 
defect is made known by pronounced symptoms. This is due to 
two causes : (a) the polyuria of the early stages of the disease 
lessens the relative amount of coloring matters in the urine, 
and it will be remembered that the pigments tend to hold the 
uric acid in solution; (b) both interstitial nephritis and uric- 
acid deposits are often the outgrowth of the same habits of 
living, viz., the overindulgence in animal foods. The author has 
repeatedly observed that people who possess generous appetites, 
and indulge in the use of animal foods two and three times 
daily, are exceedingly apt to have uric-acid deposits in their 
urine at middle age, and somewhat later to develop interstitial 
nephritis. Uric-acid deposits are frequent in cases of children 
convalescing from scarlatina, with or without accompanying ne- 
phritis, and concretions or gravel are very prone to arise under 
such circumstances. 

Urates. 

The acid urates of sodium, potassium, ammonium, and, more 
rarely, of calcium are met with as sediments in the urine. 



158 ANALYSIS OF URINE. 

The acid urate of sodium occurs chiefly as minute, irregular, 
amorphous granules, although sometimes, also, in crystalline 
form, — star-shaped, needle-like clusters, often of fan-shape ar- 
rangement. This deposit is more or less deeply stained brown 
or pink, according to the degree of pigmentation of the urine, 
since it possesses a great affinity for the above-named pigments. 

The sodium-urate deposit occurs in acid urine, and forms a 
large bulk of the " brick-dust," or mixed urate, deposit found in 




Fig. 14.— Soditjm-Ukate Crystals. (After Peyer.) 

the bottom of the vessel after the urine has cooled. Acid 
sodium urate is extremely insoluble, requiring 1150 parts of cold 
or 124 parts of boiling water to effect its solution. 

Acid potassium urate occurs only in amorphous form as a 
deposit, and, like sodium urate, forms a part of the mixed urate 
deposit met with in acid urines. It is much more soluble than 
the sodium urate. 

L Acid calcium urate occurs as a urinary deposit but rarely, 
and in minute quantities. It consists of a white or grayish 



PLATE VI. 




Ammonium Urate, showing Spherules and Thorn- 
apple-shaped Crystals. (After Peyer.) 



CHEMICAL SEDIMENTS. 159 

amorphous powder, highly insoluble, and on fusion leaves a 
white residue, consisting of calcium carbonate. The acid calcium 
urate, like the potassium and sodium urate deposits, occurs only 
in acid urine. 

Ammonium urate occurs as a crystalline deposit, consisting 
of dark-brown, spherical masses studded with fine, sharp-pointed 
spicula, — " thorn-apple crystals.'' 1 The spicula may be long, 
sometimes curved, branched, or bent, forming various shapes. 
(See Plate YI.) The smaller crystals often closely resemble 
those of sodium urate, and by some they are claimed to be 
identical. 

This sediment most frequently occurs in alkaline urine, 
associated with amorphous calcium phosphate and triple phos- 
phate crystals. The ammonium-urate deposit is, in fact, the 
only urate sediment found in alkaline urine. 

The mixed urate deposit consists of a reddish, granular- 
looking sediment, with color always deeper than the urine from 
which it precipitates. It may vary all the way from a faint 
pinkish haze to a, brick-red color. (See Plate Y.) Most fre- 
quently it sinks quickly to the bottom of the quiescent vessel, 
but part of it may long remain suspended, imparting to the 
urine an opalescent turbidity ; at the same time a pellicle may 
form on the surface or cling to the sides of the vessel, notably 
at the surface-line of the urine. By gently heating the urine the 
mixed urate sediment promptly dissolves, and this forms a 
ready method of its recognition, as no other urinary deposit 
behaves similarly. The mixed urate deposit gives the murexide 
reaction similar to uric acid. It is dissolved by solutions of 
the caustic alkalies ; with mineral acids it is decomposed, with 
resulting precipitation of uric-acicl crystals. 

It is an interesting fact that urines of high density are most 
prone to throw down deposits of mixed urates, while those of lower 
density are more apt to throw out of solution uric acid. Thus, 
with urines of specific gravity at 1026 to 1030, when they cool, 
the excess of urates come down because of their limited degree 
of solubility; while in urines of specific gravity below 1020, the 
diminished pigmentation often permits the uric acid to fall out 
of solution and form a deposit. 



160 ANALYSIS OF URINE. 

Clinical Significance. — The mixed urate deposit, like that of 
uric acid, is most frequently encountered in febrile states ; even a 
slight elevation of temperature is often sufficient to cause their 
deposit. A more constant deposit of mixed urates may be noted 
in diseases of the viscera, which entail progressive emaciation, 
notably in the liver and in the so-called wasting diseases. Func- 
tional disorders of the stomach are frequently associated with 
amorphous urate deposits, due, in all probability, to incomplete 
transformation of proteid foods. In gout the urates are usually 
deposited during the attack, but disappear upon the approach 

of convalescence. 

Oxaluria. 

Oxalate of lime is met with as a urinarj^ sediment either in 
acid or alkaline urine, but most often in the former. If it occur 
in acid urine it is often associated with uric-acid deposits, but 
when occurring in alkaline urine its most frequent associated 
deposit is the triple phosphate. 

The calcium-oxalate deposit occurs in crystalline form, con- 
sisting chiefly of two varieties of crystals, (a) and most frequent 
are the octahedral crystals, very beautiful and highly refracting. 
They are made up of four-sided pyramids, situated base to base, 
as seen in their long diameters. When viewed from the side 
they appear as squares crossed obliquely by two sharp lines, 
forming the characteristic "envelope-shaped" ciystals. When 
small, the lines crossing in the centre form a bright spot, highly 
refractive of light, — star-like, (b) The second form of calcium- 
oxalate deposit is the so-called " dumb-bell " c^stals. Their true 
form is that of ovoid or circular disc, with round margins and 
depressed at the centre on either side. Their variable appear- 
ance depends upon their different positions when viewed, as may 
be seen by causing the crystals to roll over under the cover- 
glass. 

Calcium oxalate is insoluble in alcohol, ether, water, alkalies, 
and acetic acid, but readily soluble in hydrochloric or other 
mineral acids, — characteristics which serve to identify this salt; 
but in practice the microscopical appearance is the most conclu- 
sive, since the crystals are so characteristic in form that they are 
readily distinguishable from all other crystalline deposits ; the 



I 



CHEMICAL SEDIMENTS 



161 



deposits of triple phosphate and uric acid are the only ones 
which have the least resemblance thereto. 

With regard to the triple-phosphate crystals, it is only the 
smaller, imperfect, and short prisms that are ever confounded 
with calcium-oxalate crystals. In such cases the body of the crys- 
tals, instead of forming a parallelogram, is shortened so that it 
becomes a square, and the prism then gives somewhat the ap- 
pearance of the envelope-shaped calcium-oxalate crystal. The 




U Q 

# <^9 

? Q^V ** j - 

^ # ^ 

®0 i 

Fig. 15.— Various Forms of Calcium-Oxalate Crystals. (After Peyer.) 

calcium-oxalate crystals, however, are always smaller and more 
highly refracting. Should any doubt remain, after careful ocular 
examination, they may be readily distinguished by their behavior 
with acetic acid, which promptly dissolves the triple-phosphate 
crystals, while the calcium oxalate is unaffected thereby. 

The " dumb-bell " form of uric acid may usually be distin- 
guished from the calcium-oxalate ciystals of similar form Irv the 
brown color of the former, as well as by their solubility in 

alkalies. 

li 



162 ANALYSIS OF URINE. 

Clinical Significance. — The occurrence of calcium oxalate as 
a urinary deposit is brought about by the strong affinity which 
oxalic acid possesses for calcium. Oxalic acid occurs under 
physiological conditions in very small amounts in urine, — about 
0.02 gramme in twenty-four hours. According to generally 
received opinion, it exists in the form of calcium oxalate, which 
is kept in solution by the acid phosphates of the urine. The 
quality of food taken often materially influences the degree of 
plrysiological oxaluria. Thus, vegetables containing much oxalic- 
acid combinations, — as cabbage, spinach, asparagus, sorrel, 
apples, grapes, tomatoes, turnips, and sugar, — when taken in 
excess, may cause excretion of calcium oxalate in considerable 
amount. Calcium oxalate is also excreted in excess upon an 
exclusive or excessive diet of flesh and fat, indicating its forma- 
tion from proteids. 

The question of so-called " oxalic-acid diathesis " possesses 
much practical interest. As early as 1842, Bird described a 
series of nervous and dyspeptic symptoms, which he alleged 
were associated with deposits of calcium oxalate in the urine. 
Later on, Bigbie still more minutely described the symptoms 
of the so-called " oxalic-acid diathesis" of which the following 
is a brief summary : " These patients are mostly males in the 
prime of life, ordinarily of sanguineous or melancholy tempera- 
ment, of sedentary habits, and accustomed to overindulgence 
in the luxuries of the table. Indigestion in its varied forms 
is a prominent feature. These patients are often capricious, 
sensitive, irritable, or dull, despondent, and melancholic. The 
tongue is coated and the skin is dry. In inveterate cases a 
dirty, dingy countenance, increasing emaciation, falling out of 
the hair, tendencj^ to boils, carbuncles, psoriasis, and other cuta- 
neous disorders are frequently observable. Accompanying these 
are often deep pains in the back and loins, hemorrhages from 
the intestines and bladder, incontinence of urine, impotence and 
irritation of the bladder." 

Attractive though the theory be of the so-called " oxalic-acid 
diathesis" in the light of more recent and wider observation 
the name " diathesis " seems in nowise merited by any of the 
states associated with deposits of calcium oxalate in the urine. 



CHEMICAL SEDIMENTS. 163 

It is true that oxalic acid, when taken internally in any consid- 
erable amount, exerts a poisonous action upon the organism, not 
only locally on the intestines, but also generally on the heart and 
nervous system ; and this gave rise, no doubt, to the supposition 
that a large formation of oxalic acid or its retention in the system 
might produce toxic, and even dangerous, symptoms. Distinct 
proof, however, is yet lacking to show that the symptoms of the 
so-called " oxalic-acid diathesis " are due to an accumulation of 
oxalic acid in the blood. Indeed, nearly all the evidence tends 
in the opposite direction. In the first place, large deposits of 
calcium oxalate, and even the formation of oxalic calculus, is 
repeatedly observable in people who are otherwise in the enjoy- 
ment of the most typical good health. In the second place, the 
group of symptoms described as characteristic of the oxalic- 
acid diathesis, as Roberts has observed, " is one common to the 
clinician minus the deposits of calcium oxalate." Lastly, the 
states of the system associated with deposits of calcium oxalate 
are altogether too varied to admit of so narrow a classification 
as that of a special diathesis. It seems most reasonable to con- 
clude that oxaluria is dependent upon a variety of conditions of 
the system, many of which are associated with little or no 
departure whatever from ordinary health. 

The conclusions of Beneke, who has thoroughly investigated 
this subject, are as follow : — 

1. Oxaluria accompanies the lighter or severe forms of ill- 
ness ; has its proximate cause in an impeded metamorphosis, — 
i.e., in an insufficient activity of that stage of oxidation which 
changes oxalic acid into carbonic acid. 

2. Oxalic acid has its chief source in the azotized constit- 
uents of the blood and food; hence, everything which retards 
the metamorphosis of these constituents gives rise to oxaluria. 

3. Such retardation of the metamorphosis of azotized ele- 
ments of the blood may be determined by the following causes : 
(a) excessive use of azotized articles of food ; (b) excessive use 
of saccharine and starchy articles of food; '(c) insufficiency of 
the red blood-corpuscles, entailing diminished oxidation ; (d) in- 
sufficient access to pure fresh air; (e) organic lesions which in 
any way impede respiration and circulation ; (/") conditions of 



164 



ANALYSIS OF URINE. 



the nervous system entailing depression, whether arising pri- 
marily from mental derangement or from pathological states of 
the blood. 

4. Excess of alkaline bases in the blood. 

Phosphaturia. 
It has already been shown in Section II that phosphorus 
exists in normal urine in combination with the alkalies and the 
earths, — the alkaline and earthy phosphates. It is only, how- 




Fig. 16.— Triple-Phosphate Crystals. (After Ultzmann.) 

1. Rosette or star-shaped crystals. 2. Coffin-shaped crystals. 



ever, the latter salts that are met with as urinary deposits. The 
earthy phosphates consist of (a) triple phosphate or ammonio- 
magnesium phosphate, and (6) calcium phosphate or phosphate 
of lime. 

Ammonio-magnesium phosphate (MgNH 4 P0 4 6H 2 0), or triple 
phosphate, is essentially a crystalline deposit, occurring in two 
forms. The first — most frequent and typical — form is that of a 
triangular prism with beveled ends, very distinctive and often 
termed " coffin-shaped " crystals. Many modifications of this 
typical form are met with. Thus, the crystals may be shortened 



CHEMICAL SEDIMENTS. 



165 



to the form of squares, instead of being oblong, or one or more 
corners may be absent. 

The second and less frequent form in which triple phosphate 
appears as a urinary sediment is that of star-shaped, feathery 
crystals, the points appearing not unlike fern-leaves. These are 
often but rudiments of the prismatic form of triple-phosphate 
crystals, into which latter they often become gradually trans- 




Fig. 17.— Calcium-Phosphate Crystals. (After Peyer.) 



formed, and therefore between these two forms numerous inter- 
mediate ones are to be observed (Fig. 16). 

Calcium phosphate is met with as a urinary sediment in two 
forms, — (a) amorphous, (b) crystalline. The amorphous form 
of calcium phosphate is a whitish, flocculent deposit, often mis- 
taken by the naked eye for pus or granular organic matter, and 
when precipitated from the urine b}^ heat it is sometimes mis- 
taken for albumin. Under the microscope this sediment appears 
in the form of minute, pale granules, arranged in irregular 
patches. 



166 ANALYSIS OF URINE. 

The crystalline form of calcium phosphate is a comparatively 
rare deposit, occurring less frequently than any other form of 
phosphatic deposit. Its essential or elementary form is that 
of cr3 T stalline rods, sometimes lying unarranged, but more often 
grouped in stellar or rosette form, while often they may be 
observed grouped in club or wedge form, but always marked by 
lines of ciystallization (Fig. 11). The earthy phosphates are 
essentially a product of alkaline urine, and, with the exception 
of the crystalline form, the}^ are never met with in acid urine. 
The above-named exception only occurs with feebly -acid urine 
tending to ammoniacal change. 

The following are the chief conditions of the urine which lead 
to phosphatic sediments : — 

(a) If the urine be alkaline from fixed alkali. 

(b) If the eartlry phosphates be in excess (the urine being 
alkaline or neutral). 

(c) If the urine be alkaline from volatile alkali, the result of 
decomposition of urea into ammonium carbonate in the urinary 
passages, the ammonia uniting with the magnesium phosphate 
to form the triple phosphate of ammonium and magnesium. 

Clinical Significance. — In those cases in which the phosphatic 
deposit occurs in alkaline urine from fixed alkali, the deposit is 
chiefly precipitated calcium phosphate, though often mixed with 
triple-phosphate crystals. The urine in these cases is usually 
of high specific gravity, alkaline in reaction when voided, more 
or less cloudy, and effervesces upon the addition of acid, after 
which the urine immediately clears. The clinical sj^mptoms cor- 
responding to the above are often those of general debility, 
with feeble respiration — favoring the accumulation of carbonic 
acid in the s} T stem. Thus, in convalescence from exhausting 
acute diseases, deposits of calcium phosphate are frequently to 
be noted. Flatulent dyspepsia is a frequent cause of alkaline 
urine from fixed alkali and the deposit of calcium phosphate. 

As Ralfe has pointed out, the acids formed by fermentative 
changes being of the fatty acid series, upon entering the blood 
they are oxidized into carbonic acid, and, uniting with the bases 
of the alkaline oxides from carbonates of these bodies, increase 
the alkalescence of the blood and in consequence diminish the 



CHEMICAL SEDIMENTS. 167 

acidity of the urine or even render it alkaline, which permits the 
phosphates to fall out of solution. This is most frequently 
noted in debilitated persons with flatulence of the small intes- 
tine. It is associated with such features as loss of weight, 
irregular bowels, sallowness of complexion, despondency, and 
frequent micturition. 

In those cases in which the deposit of calcium phosphate is 
the result of excessive elimination, very often marked systemic 
disturbances are associated therewith. The urine is usually 
alkaline, copious in volume, and the deposit is of dense whitish 
form. If persistent, the symptoms are usually those of nervous 
irritability, dyspepsia, emaciation, and backache. Sometimes 
symptoms akin to diabetes are observable in inveterate cases, 
and the condition has been called " phosphatic diabetes. 11 Indeed, 
it is claimed that this condition not infrequently ends in diabetes 
insipidus. 

The deposit of the c^stailine form of calcium phosphate in 
quantity is, in the experience of Roberts, often " an accompani- 
ment of some grave disorder," such as cancer of the pylorus, 
phthisis, and exhaustion from obstinate chronic rheumatism. 

In cases of phosphatic deposits in the urine resulting from 
the presence of volatile alkali, the sediment, as before stated, is 
that of triple phosphate of ammonium and magnesium. It has 
already been shown that ammoniacal fermentation always occurs 
in healthy urine upon standing sufficiently long, and then the 
triple phosphates are precipitated. But in the class of cases 
under present consideration the urine is alkaline when voided 
and precipitation of triple phosphates takes place immediately. 
In these cases ammoniacal decomposition of the urine occurs in 
the urinary passages. In addition, therefore, to the triple- 
phosphate deposits in such cases, the urine also contains pus 
and more or less mucus. 

The clinical symptoms attending this state of the urine are 
most often those of septic inflammations of the urinary passages, 
such as pyelitis and cj^stitis. The most frequent class of causes 
of this condition of urine are the obstructive diseases of the 
lower urinary conducting channels. Whatever cause operates 
to retain the urine in the bladder sooner or later gives rise to 



168 ANALYSIS OP URINE. 

C3 r stitis and the deposit of triple-phosphate crystals. Thus, in 
enlarged prostate, at on} T and paralysis of the bladder, paraplegia, 
and diseases of the lower spinal cord, the urine nearly always 
precipitates the triple phosphates. This condition of urine 
nearly always precedes so-called " surgical kidney", and those 
septic conditions so dangerous to life which result from the use 
of instruments in the lower urinary channels. Therefore, when 
the urine is found to contain deposits of triple phosphate with 
pus, and is alkaline when voided, it constitutes a signal for the 
exercise of the greatest possible caution on the part of the sur- 
geon in passing instruments into the urethra and bladder for the 
first time, more especially in the cases of elderly men. 

It is well known that men addicted to exhaustive mental 
labor and people laboring under worry and anxiet}' are apt to 
have precipitates of earthy phosphates in their urine. If to 
such conditions be added habits of vegetarianism, which tend 
to depress the acidity of the urine, triple phosphates in addition 
may readily fall out of solution and form deposits. 

Cystinuria. 

Cystin (C 3 H 6 XS0 2 ) is comparatively rarely met with as a 
urinary deposit. Its origin in the economy is not clearly under- 
stood, although its highly sulphurous composition (about 25 per 
cent.), together with its close resemblance in composition to 
taurin, suggest the possibilit3 T that the liver may be its source. 
The discovery of cy T stin in the livers of typhus patients by 
Scherer, as well as the discovery of cystinuria in cases of dimin- 
ished bile secretion \>y Marowski, would further favor the above 
view. Stadthagen claims that cystin is absent from normal 
urine, though Goldman and Baumann succeeded in separating it 
in very small quantities from healthy urine as a benzoyl com- 
pound. 

Cj^stin is a crystalline compound of feeble chemical affinities, 
and occurs in two forms, (a) most commonly in six-sided tablets 
of variable sizes, and somewhat resembling the six-sided crystals 
of uric acid. These tablets possess an opalescent lustre, — 
u mother -of *-pearl " appearance, — and when traced with fine lines 
of secondary ciystallization, or formed into rosettes, they pre- 



CHEMICAL SEDIMENTS. 169 

sent microscopical pictures of great beauty, (b) The second 
form of cystin crystals is that of four-sided square prisms, which 
lie separately or in stellate form. They are highly refractive, 
and when their sides lie out of the direct line of vision they 
appear almost black, forming a strong contrast with those sides 
presented vertically to the light, which appear of a brilliant-white 
color. Cystin is soluble in the caustic alkalies, oxalic and strong 




Fig. 18.— The More Common Form of Cystin Crystals. (After Peyer.) 

mineral acids. It is insoluble in boiling water, acetic acid, alco- 
hol, and ether. 

Differentiation. — Cystin may be readily distinguished from 
the pale, lemon-colored, six-sided crystals of uric acid, as follows : 
Permit a drop of ammonia to mingle with the deposit on a glass 
slide, when either form of crystals disappear. Next, evaporate ; 
and if cystin be present the crystals re-appear, showing that they 
were merely in solution. If, on the other hand, the crystals 
were uric acid, no re-appearance occurs upon evaporation, but, 



110 ANALYSIS OF URINE. 

instead, crystals of ammonium urate appear, showing chemical 
combination, and not solution. 

Another simple method consists in treating the crystals with 
oxalic or hydrochloric acid, which promptly dissolves cystin 
crystals, but leaves uric acid unchanged. 

From triple-phosphate crystals cystin is readily distinguished 
by its behavior with acetic acid, the former being immediately 
dissolved therewith, while cystin remains unchanged. 

The urine containing cystin is usually pale in color, of faintly- 
acid reaction, and upon standing develops the odor of sulphu- 
retted hydrogen, as well as that of ammonia. The sediment is 
of pale-lemon color, and often changes to green upon standing. 

Clinical Significance. — Unfortunately but little at present of 
a positive nature is known as to the clinical relations of cystin- 
uria. Its frequent association with hepatic disorders may be 
said to be established. Cystin deposits are said to be results of 
extensive renal degenerations. Chlorotic women and strumous 
children are also believed to be prone to cystic deposits in their 
urine. Ebstein has noted the presence of cystin deposits together 
with albumin in the urine in cases of acute articular rheumatism. 
Cystin deposits have been known to occur repeatedly in the same 
family by a number of independent observers, among whom are 
Marcet, Lenoir, Civiale, Toel, and Ebstein. Cystin calculus 
is well known to run in certain families. Cystinuria is said to 
be most common in young males, although no age or sex can be 
said to be exempt from it. It may be present and continue for 
years without any noticeable impairment of health. 

The chief interest connected with cystic deposits is their 
proneness to form concretions of cystin gravel ; and although 
these are comparatively rare occurrences, their consequences are 
none the less serious when occasionally encountered. 

Leucinuria and Tyrosinuria. 
Leucin (C 6 H 13 N0 2 ) and tyrosin (C 9 H 11 JS T 3 ),as will be seen 
from their formulae, are closely related, being products of decom- 
position of proteid bodies or of their derivatives. Since they are 
nearly always found associated with each other in the urine, they 
will be considered together. 



CHEMICAL SEDIMENTS. Ill 

Leucin occurs as a urinary sediment for the most part in the 
form of yellowish, highly-refracting spheres, though not quite so 
highly refracting as oil-globules, which they somewhat resemble. 
In a pure state it crystallizes in scales or rosettes, often of irreg- 
ular shapes, and it has a greasy feel. Leucin is insoluble in 
ether, which readily distinguishes it from oil-globules. It is also 
insoluble in mineral acids, but is partly soluble in water and alcohol 
and is completely soluble in caustic alkalies. For ordinary 




Fig. 19.— Leucin and Tyrosin. (After Peyer.) 

practical purposes leucin may be known by the microscopical 
appearance of the crystals, and in this wajr very minute traces 
may be determined with certainty. Confirmation by chemical 
tests may be employed if a fair amount of the material be at 
hand, (a) Thus, solutions heated with proto-nitrate of mercury 
give deposits of metallic mercury (Hoffmeister). (6) When 
fused with nitric acid on platinum-foil it leaves a colorless residue, 
which if heated with potassium hydrate forms drops of an oil-like 
fluid which do not adhere to the platinum (Scherer). (c) Upon 



1*72 ANALYSIS OP URINE. 

heating leucin in a glass tube open at both ends to about 110° C. 
it sublimes in feathery particles, which float about in the air 
within the tube. Further heat causes it to fuse and mostly dis- 
appear into carbonic acid and amilymin. Leucin may be sepa- 
rated from the urine by evaporating the latter and dissolving the 
residue in boiling alcohol. Upon cooling the leucin present will 
be deposited in whitish plates or masses. Leucin is normally 
present in the liver, pancreas, spleen, lymph glands, salivary 
glands, and in the thyroid and thymus glands. 

Tyrosin crystallizes in the form of very fine needles, arranged 
in sheaf-like collections. In masses the crystals are snow-white, 
tasteless, and odorless. If crystallized from an alkaline solution 
tyrosin often assumes the form of rosettes composed of fine 
needles arranged radiately (Fig. 19). Tyrosin is insoluble in 
alcohol and ether, feebly soluble in cold water, readily soluble in 
acids, alkalies, and hot water. Aside from its crystalline form 
and characteristic solubilities, tyrosin may be readily recognized 
by several pronounced reactions. 

(a) Hoffmann's Reaction. — When heated with Millon's reagent, 
solutions of tyrosin yield a brilliant crimson or pink coloration, 
which, if much tyrosin be present, is accompanied finally by a 
similarly-colored precipitate. The test in its original form was 
applied by heating with a solution of mercuric nitrate in presence 
of nitrous acid. 1 

(b) Piria's Reaction. — If tyrosin be moistened on a watch- 
glass with concentrated sulphuric acid, and warmed for five or 
ten minutes on a water-bath, it turns pink, owing to the formation 
of tyrosin-sulphonic acid— C 9 H 10 (SO 2 OH)NO 3 -f 2H 2 0. This 
is then diluted with water, warmed, neutralized with barium 
carbonate, and filtered while hot. The filtrate yields a violet 
color on the careful addition of very dilute perchloride of iron. 
The color is readily destroyed by an excess of the iron salt. 

(c) Tyrosin gives out the odor of phenol and nitro-benzol 
upon heating (Kuhn). Tyrosin may be separated from the 
urine by first precipitating the coloring matters and extractives 
of the urine by means of basic lead acetate, then decomposing 
the filtrate with sulphydric acid and again filtering. Upon 

1 Liebig's Annal., Bd. lxxxvii, 1853, S. 124. 



CHEMICAL SEDIMENTS. 173 

evaporating the filtrate to the thickness of syrup, tyrosin crys- 
tals will be deposited upon cooling. 

Clinical Significance. — Leucin and tyrosin, as already stated, 
usually occur together, and this applies both to the urine and the 
organism at large. Being products of decomposition of proteids, 
they form in the system in very minute quantities, if at all, 
during normal metamorphosis. When metamorphic changes of 
a retrograde nature are rapid, as in extensive suppuration and 
gangrene, they form in large amounts. They may in such cases 
pass into the urine, largely supplementing urea. 

Leucin and tyrosin are found in the urine in acute atrophy 
of the liver, in acute phosphorus poisoning, often in very con- 
siderable amounts. They have also been observed in the urine in 
cases of leucocythsemia, typhoid, and small-pox. 

Melanuria. 

Melanin is a black pigment which occurs pathologically in 
the urine under various circumstances. It is insoluble in cold 
alcohol, ether, acetic acid, and dilute mineral acids. It is soluble 
in boiling, strong mineral acids, in boiling acetic and lactic 
acids, and in strong solutions of sodium, potassium, and am- 
monium hydroxid. 

Melanin contains carbon, nitrogen, iron, and sulphur, — the 
latter in large amount. The urine containing melanin is not 
usually dark when voided, but it soon becomes so upon exposure 
to the atmosphere, and it becomes intensely black if submitted to 
such oxidizing agents as sulphuric and hydrochloric acids and 
chloride of iron. Melanin occurs as a urinary deposit in the 
form of small, lumpy granules, much resembling carbon parti- 
cles. In the urine it may be detected by several reactions : 
(a) By the addition of bromine-water to urine containing 
melanin a yellow precipitate is deposited, which gradually 
blackens. This is considered by Zeller the most delicate test 
for melanuria. (b) When melanotic urines are treated with solu- 
tions of ferric chloride, they 3 r ield, according to the concentra- 
tion of the reagent, either a dark-brown cloudiness or else a 
black precipitate, soluble in excess of the precipitant. This test 
is both delicate and characteristic, (c) When melanin is present 



114: ANALYSIS OF URINE. 

in the urine, if treated with a dilute solution of nitro-prusside 
of sodium and some caustic potassium be added, a pink or red 
coloration usually appears, which turns blue on the addition of 
acids, owing to the formation of Prussian blue. The latter 
reaction is not due to the melanotic pigment, but to some other 
substance simultaneously excreted. 

Clinical Significance. — Melanuria is frequently observed in 
people who are subjects of pigmented tumors, notably melanotic 
cancer or sarcoma. It has also been observed in people suffering 
from repeated attacks of intermittent fevers. The urine of 
people in wasting diseases sometimes contains considerable de- 
posits of melanin. The practical significance of melanuria, as 
Jaksch has pointed out, is greatly weakened by the facts that the 
urine may contain a large quantity of melanin in wasting dis- 
eases, while in melanotic cancer or sarcoma the urine may be free 
from it. For diagnostic purposes, therefore, so far as sarcoma 
is concerned, it should only be regarded as adjunct. 

Lipuria. 

Normal urine contains small amounts of fatty matter, pal- 
matin, and stearin, — about 2 grains per gallon. It is probable 
that these neutral fats are increased upon a fatty diet, since 
numerous cases are recorded in which fat has been found in 
abnormal quantities unaccompanied by pathological conditions. 
Fat is soluble in hot alcohol, ether, benzol, carbon disulphide, 
and chloroform. When mixed with colloids in an alkaline solu- 
tion, fat is broken up into fine globules, becoming white like 
milk, — an emulsion. Under the microscope fatty sediments 
appear in the urine in the form of highly -refracting globules of 
various sizes, with dark and somewhat irregular margins. If the 
urine contain fat in considerable quantity, it is usually of a milky 
color, but this readily clears by shaking it with ether. 

Clinical Significance. — Small quantities of fat are frequently 
met with in the urine in chronic parenchymatous nephritis, in 
fatty changes in the kidneys, in phosphorus poisoning, and in 
diabetes mellitus. In one case of diabetes mellitus the author 
met with a large amount of fat in the urine, the occurrence of 
which was intermittent, alternating with the appearance of sugar. 






CHEMICAL SEDIMENTS. 115 

Ralfe also states that he found an abundance of oil-globules in 
the urine of a patient who died of diabetic coma. Ebstein 
found a large amount of fat in the urine in a case of hydro- 
nephrosis. Lipuria is a physiological condition with pregnant 
women. Roberts has recorded several cases in which pure oil 
appeared in the urine after the administration of codliver-oil. 
Henderson has reported three cases of lipuria associated with 
heart disease. 

In diseases of the pancreas lipuria is not uncommon, and 
in such cases lipuria has appeared before oil was to be noted in 
the stools. Fat is also frequently observed in the urine after 
fracture of bones and during the course of repair. In acute 
yellow atrophy of the liver, followed by fatty changes in the 
renal epithelium, the urine contains an excess of fatty matters. 

In chyluria the urine contains a large amount of fatty matters 
as well as albumin and blood-corpuscles. The features of this 
disease, however, will be fully considered in a future section of 
this work. 



SECTION VII. 

ANATOMICAL SEDIMENTS. 

HEMATURIA. 

Blood-corpuscles appear as a urinary sediment in a number 
of conditions, all of which are pathological. Their appearance 
varies according to the character of the urine in which they 
are found, and the location of the tract from which they exude. 
The typical microscopical appearance of blood-corpuscles is so 
characteristic that little difficulty is encountered in distinguishing 
them from all other urinary sediments (Fig. 20). Their original 
form is that of biconcave discs of yellowish color. In focusing 




%m Q 



Q.0 ©3~ 



Fig. 20.— Normal B:lood-corpusc:les. (After Peyer.) 

with the fine adjustment of the microscope, the margins of the 
corpuscles undergo reversal of light and shade owing to their bi- 
concave form. Blood-discs are distinguished from pus-corpuscles 
by the absence of visible cell-contents and nuclei of the former. 

In acid urine blood-corpuscles long retain their characteristic 
features, although in time they shrivel somewhat, and become 
dentated at their margins — more or less stellate in form. In urine 
they do not, as a rule, tend to run together, or to form rouleaux 
as when drawn from a blood-vessel, but are for the most part 
distributed pretty evenly over the field of vision. Exceptions to 
(176) 



ANATOMICAL SEDIMENTS. 177 

this rule sometimes occur in cases of pronounced haemorrhage 
from the bladder or urethrse. 

If the urine be concentrated the biconcave character of blood- 
corpuscles becomes exaggerated, but the corpuscles shrink some- 
what and are more apt to become indentated or jagged at their 
margins. On the other hand, if the urine be dilute — i.e., of low 
specific gravity — the corpuscles swell and become biconvex, or 
even spherical, and at the same time they lose their optical 
characteristics as well as their coloring matters. This occurs 
the more readily if the urine be amnion iacal. 

The urine containing blood is usually cloudy and more or less 
reddish in color, according to the quantity present. If the quan- 
tity of blood be considerable and the urine be acid the color is 
dark red, but if the urine be alkaline the color is bright red. If 
the quantity of blood in the urine be small the color may give 
no indication of its presence, especially if the urine be concen- 
trated. Generally speaking, if the blood come from the kidneys 
it is diffused evenly through the urine, imparting to the latter a 
reddish, hazy tint. If, on the other hand, the blood be derived 
from the lower urinary tract, the color is usually bright, and clots 
are not infrequently present. Lastly, if blood appear in the urine 
in quantities however small, a distinct albuminous reaction is 
always obtainable. 

Clinical Significance. — The clinical significance of hematuria 
embraces a very wide and varied class of pathological conditions. 
In order, therefore, to afford any practical information it must 
first be determined from what source the hematuria arose. 

In haemorrhages from the kidney the urine is usually of an 
homogeneous, reddish-brown color, of acid reaction, of lowered 
specific gravity, and it often contains renal casts and renal 
epithelium. After standing the urine deposits more or less 
brown, coffee-colored sediment. If pyelitis be present, the urine 
may have an alkaline reaction. In hematuria of renal origin 
clots are usually absent from the urine, unless they be of the 
long, slender, rod-like variety, showing that they have been 
molded in passing through the ureters. The recognition of 
blood-casts in the urine forms the most conclusive proof of the 
renal origin of hematuria. The most frequent cause of renal 



178 ANALYSIS OF URINE. 

hematuria is the class of renal diseases grouped together under 
the term of Bright 's disease. In the acute forms of these lesions 
hematuria is nearly always present. The haemorrhage is not 
very pronounced in these cases, being of parenchymatous origin. 
It usually subsides with the more acute symptoms of the disease. 
Of the chronic Bright's lesions the interstitial form is the most 
frequent cause of haernaturia, and in such cases the haemorrhage 
is the most pronounced and obstinate of all renal haemorrhages, 
except that from malignant and cystic disease of the organs. 
This is due to the accompanying vascular changes, including 
cardiac enlargement and atheromatous arteries. 

Anryloid disease less frequently gives rise to haematuria, 
although it is by no means rare in such cases, since the small 
renal vessels in this disease undergo pronounced degenerative 
changes. In chronic diffuse inflammatory lesions of the kidney 
haematuria is almost unknown. 

Malignant growths of the kidney give rise to most trouble- 
some, profuse, and repeated attacks of haematuria. Such cases 
are to be recognized by renal tumor, pain, and general cachexia 
of the patient. Tubercular disease of the kidney not infrequently 
gives rise to haematuria. The urine in such cases contains more 
or less pus and broken-down tissue debris which do not alto- 
gether subside as a sediment. Haematuria from tuberculosis, 
like in cancer, is intermittent in character, and there ma} T also be 
present tumor, but usually no pain. The diagnosis rests upon the 
general symptoms of tuberculosis, such as emaciation, elevation 
of temperature, etc. ; but most conclusively upon the isolation 
and propagation of the bacillus tuberculosis from the urine. 

Renal calculus, whether confined to the kidney or, as is more 
frequent, when occupying the renal pelvis, nearly always gives 
rise to haematuria sooner or later. In these cases the haemor- 
rhage is most marked upon exercise, and usually diminishes or 
subsides upon continued rest. Pus-cells are always present in 
the urine in haematuria of calculous origin. Fixed pain in the 
region of the kidney, usually with tenderness upon deep pressure 
over a certain point, sometimes retraction of the testicle as well 
as reflected pain upon the affected side, often extending down the 
leg, serve to diagnosticate haematuria of calculous origin. 



ANATOMICAL SEDIMENTS. 179 

In endemic hematuria of the tropics the cause is due to a 
minute parasite in the kidney — Bilharzia hsematobi — which will 
be described later on. Among the other causes of hsematuria of 
renal source may be mentioned cystic disease of the kidneys, 
abscess, renal embolism, lrydatids, acute febrile processes, purpura 
hsemorrhagica, uterine and crural phlebitis. Renal hsematuria 
may arise from the ingestion of certain drugs, as turpentine, can- 
tharidis, and a number of toxic substances. Lastly, hsematuria 
of renal origin may arise in consequence of traumatisms involving 
the kidneys, either directly as by blows or wounds, or indirectly 
from concussion. 

In vesical hsematuria the urine is usually alkaline in reaction, 
always so if accompanied by cystitis of long standing. In such 
cases the urine is ammoniacal and thick from muco-pus, and 
crystals of triple phosphate are usually present. In vesical 
hsematuria clots are more common than in other forms of haemor- 
rhage. These are usually of an irregular or ragged shape. The 
blood is brighter in color and less intimately mixed with the 
urine than in hsematuria of renal origin. Stone in the bladder 
is perhaps the most frequent cause of hsematuria of vesical 
origin, and, in such cases, the blood is almost normal in appear- 
ance and is passed mostly at the close of the act of micturition. 
The grade of hsematuria in these cases depends largely upon the 
acuteness of the attack. In cystitis of the vesical neck the 
symptoms closely resemble those of stone. The most pronounced 
hsematuria of vesical origin is that associated with villous 
growths and carcinoma of the bladder-walls. The urine is 
usually normal in quantity and specific gravity in such cases, 
and the reaction is usually feebly acid. The sediment is brownish 
red, flocculent,and often contains flesh-colored fibres and shreds. 
The quantity of blood may be so pronounced in these cases as 
to cause coagulation within the bladder, or, as is more frequent, 
shortly after the urine is voided. Vesical hsematuria is also 
common with neoplasms of the organ, fibrous tumors, polypi, 
and varicose conditions of the vesical neck. 

Hsematuria of urethral origin may be known by the haemor- 
rhage preceding the flow of urine as well as between the acts of 
micturition, the urine itself being usually unaltered in any of its 



180 



ANALYSIS OF URINE. 



essential characters. It may arise from acute gonorrhoea, neo- 
plasms, traumatisms, urethral chancre, or from surgical operations 
such as cutting or divulsion of strictures. 

Pyuria. 

Pus may be derived from any part of the urinary tract and 

appear in the urine as a sediment. The urine containing pus is 

always more or less turbid when voided, and gives the albuminous 

reaction. In their normal state pus-corpuscles appear under the 




Fig. 21.— Pus-corpuscles. (After Ultzmann.) 

1. Normal corpuscles. 2. Pus-corpuscles with prolongations showing amoeboid move- 
ments. 3. Pus-corpuscles with nuclei rendered distinct by acetic acid. 4. Pus-corpuscles 
altered by chronic pyelitis. 5. Pus-corpuscles swollen by ammonium carbonate. 

microscope as circular, pale, finely -granular discs, averaging in 
size nearly double that of the red blood-corpuscle. They contain 
distinct nuclei, which are often multiple, — two or three. If pus 
be diluted with water, the corpuscles may be observed to slowly 
swell up and become paler, with more delicate outlines. This 
process is more quickly produced by acetic or other organic acid, 
which renders the nuclei very distinct, but causes the granulated 
appearance of the cell-protoplasm to disappear (Fig. 21). 

Pus-corpuscles are similar to, indeed practically identical 
with, mucous corpuscles, the white corpuscles of the blood and 



ANATOMICAL SEDIMENTS. 181 

lymph. When examined in the fresh state they exhibit the 
amoeboid movements, and also show the usual glistening appear- 
ance of living protoplasm. As seen in the urinary sediment, 
pus-corpuscles are dead, the protoplasm being coagulated into 
coarse granules. 

The chief constituents of pus-corpuscles are albuminous bodies, 
of which the largest proportion is nucleo-albumin, which is in- 
soluble in water, and which expands into a tough, slimy mass 
when treated with sodium-chloride solution. This substance is 
soluble in alkalies, but quickly changed thereby into Rovida's 
hyaline substance. Besides this pus-corpuscles contain an albu- 
minous substance which coagulates at 49° C, as well as serum- 
albumin and peptone. The cell-protoplasm also contains, in addi- 
tion to the above, lecithin, cholesterin, xanthin bodies, fat, soaps, 
and cerebrin. In pus from congested abscesses which have 
stagnated some time there is peptone, leucin, and tyrosin, free 
fatty acids and volatile fatty acids, such as formic acid, butyric 
acid, valerianic acid. Pyin also is a specific constituent of 
pus, — a nucleo-albumin precipitable by acetic acid. 

Pus may be derived either from the free mucous surface of 
the urinary tract, an ulcer, or from tissue-substance, and in each 
case it is likely to be mixed with elements from its place of 
origin which become of great diagnostic value. In addition to 
this pus-corpuscles themselves frequently contain micro-organ- 
isms which explain the pathological conditions of the parts from 
whence they are derived. Pus-corpuscles are greatly changed 
by contact with potassium or ammonia ; the corpuscles swell 
up and coalesce into an homogeneous, sticky mass, in which all 
but the nuclei are indistinguishable by the microscope. Am- 
moniacal urine containing pus deposits a vitreous-looking, slimy 
mass, so sticky that in decanting it from a vessel it slips out en 
masse. The peculiar behavior of pus with caustic alkalies just 
alluded to forms the principle of Donnes's test for pus, by which 
the latter may usually be known without recourse to the micro- 
scope. The test is performed as follows : After the sediment has 
settled to the bottom of the glass or test-tube, pour off the 
supernatant urine and add liquor potassa? to the deposit. 
If the sediment be pus it is at once converted into a glaiiy, 



182 ANALYSIS OF URINE. 

gelatinous-like substance which adheres to the glass or flows in 
a mass. 

The turbidity of the urine containing pus, as well as the sedi- 
ment itself, often resembles that due to the pale, granular urates. 
The distinction, however, is easy, since heat dissipates the 
turbidity due to urates, while it only serves to increase the cloud 
due to the presence of pus by coagulating its contained albumin. 
The pus-deposit also frequently resembles the earthy phosphatic 
sediment, but the distinction here is also easy. The addition of 
an acid promptly dissolves the phosphate deposit, while it only 
increases the turbidity due to pus by coagulating its contained 
albuminous elements. 

Clinical Significance. — Of all sediments met with in the urine 
that of pus is the most common. Airv affection of any part of 
the urinary tract, from the slightest forms of irritation up to the 
gravest lesions, are usually accompanied by pyuria. The clinical 
significance of pyuria, therefore, embraces a wide range of 
pathological conditions. 

The first point to be determined, if possible, is to locate the 
particular field of the urinary tract from whence the pus origi- 
nated. This may often be determined by the general characters 
of the urine, together with the nature of the accompanying de- 
posits. When pus originates from the kidney or renal pelvis 
the urine is most apt to retain its normal acidity. Round epi- 
thelium and even casts m&y be present, and if so it gives the 
most conclusive evidence of the source of the pyuria, especially 
the presence of casts. When the pyuria has its source in the 
kidney or renal pelvis the pus is intimately mingled with the 
urine when voided, but it quickly settles upon standing, forming 
a whitish, nocculent sediment. The absence of bladder sj^mp- 
toms in pyuria goes far toward establishing the renal source of 
pyuria. 

Pyuria is usually associated with such renal lesions as chronic 
diffuse inflammations, pyonephrosis, pyelonephritis, cancer, tu- 
berculosis, and nephritic abscess. In p3*elitis, either of calculous 
or obstructive origin, pyuria is alwaj's a prominent accompanying 
symptom. 

When pyuria is of vesical origin the urine is often alkaline — 



i 



ANATOMICAL SEDIMENTS. 183 

ammoniacal — when voided ; if not, it soon becomes so upon 
standing. The urine is likely also to contain considerable mucus ; 
so that the deposit is more glairy and sticky than in renal pyuria. 
In addition to pus the urine is likely to contain such associated 
deposits as amorphous and triple phosphates and flat epithelium 
in excess from the bladder-walls. Local symptoms such as fre- 
quent and painful micturition aid in pointing to the source of 
the pus-formation. 

Cystitis of all grades is always associated with pyuria, and 
the quantity of pus-deposit in these cases is often pronounced. 
Obstructive cj^stitis, vesical stone, ulceration, tuberculosis, and, 
in short, all bladder affections are ordinarily associated with 
pyuria. 

In uncomplicated diseases of the prostate pus appears fre- 
quently in the urine, often in the form of threads long drawn 
out. Somewhat similar threads of muco-pus appear in the urine 
in chronic gonorrhoea. These are often rolled into little balls 
b} r the stream of urine as it flows down the urethral canal. The 
pyuria in acute gonorrheal conditions is almost self-evident as 
to its source. If any doubts arise upon the question they may 
be readily settled by directing the urethra to be flushed, when 
the urine voided immediately after will be free from pus, if of 
urethral origin. 

Determination of Blood and Pus in the Urine. — When, as is 
frequently the case, the urine contains a very considerable quan- 
tity of blood or pus, it is of practical importance to be able readily 
to determine the amount of either from day to day, in order to 
estimate the results of treatment. This may be rapidly accom- 
plished by means of the author's percentage tubes and centri- 
fuge. The process consists simply in sedimenting the urine in 
the percentage tubes until the urine is clear, the sediment being 
completely packed in the tips of the tubes, when the bulk per- 
centage may be read off from the scale. 

Epithelium. 
Epithelium from some part of the urinar}^ tract usually 
forms a part of every urinary deposit, and, furthermore, it is usual 
to find scattering epithelial cells in the urine when the latter is in 



184 ANALYSIS OF URINE. 

all respects normal. Epithelium is the normal product of mucous 
surfaces, and may be expected to be found in small amounts in 
any given sample of healthy urine. But in diseased states of the 
urinary tract the lining epithelium is often thrown off in very 
considerable amount, forming plainly -visible urinary sediments. 

It was formerly believed that the various divisions of the 
urinary tract possessed their own special forms of epithelium, and, 
therefore, the special forms of epithelial cells found in the urine 
became valuable aids in locating the seat of lesions of the urinary 
tract. This view is, indeed, still held by a number of prominent 
observers. More accurate and extensive observations, however, 
have shown that this can only be depended upon in a very 
general way. Yery often the epithelium claimed to be charac- 
teristic of certain divisions of the urinary tract has been found 
in all its t} T pical peculiarities in a totally different location. This, 
however, is the more likely to be the case in divisions most 
nearly located to each other. The divergent views upon this 
point, held even by the ablest and most experienced observers, 
may be illustrated by the following : Sir William Roberts 
describes the epithelium shed from the renal pelvis as that of 
" very irregular, spindle-shaped, tailed, three-cornered, elongated, 
rudely circular, etc." Dr. Dickinson has carefully figured the 
epithelium taken from the bladder, and, in reply, laconically 
observes : " It will be seen that these varieties of form, even to 
the et cdetera, are equally characteristic of vesical disease." 

The epithelium in the urine may be classed under three 
divisions (Fig. 22) : (a) Small round cells, spheroidal, finely 
granular, with comparatively large nuclei and nucleoli, the latter 
excentrically located. They occur singly or collected into groups ; 
in the latter case often cohering rather firmly, so that they float 
about in masses. They sometimes contain fatty matter, when 
springing from long-diseased locations. These cells may be 
found in their most typical form in the convoluted tubes of the 
kidney. The}^ also occur in the deep layers of the mucous tract 
of the renal pelvis, bladder, and male urethra. These cells are 
to be distinguished from pus-cells by their somewhat larger size, 
larger and more distinct single nucleus, requiring no acetic acid 
to develop or bring the nucleus into view. No positive conclu- 



ANATOMICAL SEDIMENTS. 



185 



sions can be drawn from the mere appearance of these cells in 
the urine in reference to the precise location from which they 
originated. It may be the kidney, renal pelvis, ureter, bladder, 
urethra, or urethral glands. If, in a given deposit, the round 
cells in their typical form greatly predominate, and if the urine 
contain albumin and there be other evidences of renal disease, 
it may be inferred that the cells come from the kidney, (b) The 
second form of epithelium met with in the urine is the columnar 
variety. These cells are of irregular, though always elongated, 
form. They are described as caudate-, spindle-, and cylindrical- 
shaped. They are inclined to angularity in outline, and, like the 
round cells, have a well-marked nucleus, visible without the 




Fig. 22.— Epithelium from Various Parts of the Urinary Tract. 
(After v. Jaksch.) 

a, at, squamous epithelium; b, bt, bit, epithelium from the bladder; c, ct, ctt, cttt, 
epithelium from the kidney ; d, dl ', fatty epithelium from kidney ; e to h, epithelium from 
the bladder. 

action of reagents. They may occur singly or in groups. The 
columnar epithelium may be derived from the superficial layer 
of the mucous membrane of the renal pelvis, or from the deep 
layers of the bladder, ureters, or urethra. The statement of 
Ebstein, 1 that tailed epithelial cells associated with pyuria con- 
stitute the most positive evidence of pyelitis, is quite untenable. 
More recent and accurate observation has ampty demonstrated 
that these cells exist in all their typical forms throughout the 
whole urinary tract, excepting the kidney itself, (c) The third 
variety of epithelium met with as a urinary sediment is the 



1 Von Ziemssen's Cyclopaedia of Medicine, vol. xvi, p. 



574, 



186 ANALYSIS OF URINE. 

squamous or pavement form. These cells are large, flat, some- 
what rounded, though irregular in outline, and have a distinct 
and usually central nucleus, very prominent without the aid of 
reagents. These cells are derived chiefly from the bladder and 
vagina ; in the latter case the cells are usually larger than those 
from the bladder. 

Clinical Significance. — As already stated, little more than 
inferences are to be drawn from the appearance of a particular 
form of epithelium in the urine, as to the precise location of its 
origin. While certain forms of epithelium predominate upon the 
superficial surface of the mucous tract in certain locations, the 
deeper hiyer always contains transition cells, which approach 
more nearly those of the surface layer in other locations. In 
diseased conditions, therefore, cells are thrown off from both the 
surface and deep layers, and the epithelium is nearly always, 
accordingly, of mixed varieties. 

But if we are unable to locate the anatomical seat of a lesion 
by the character of the deposited epithelium, we may, neverthe- 
less, gather information of value as to the nature of the patho- 
logical condition present from the exfoliated cells found in the 
urinary sediment. With regard to renal lesions, it may be stated 
that practically the whole class of so-called B right's lesions are at- 
tended by epithelial sediments in the urine. In the acute diffuse 
inflammations of the kidney the round epithelial cells from the 
urinary tubes are often thrown off in large quantity, so as to form 
a very considerable sediment. For the most part, in such cases, 
the epithelium is in a good state of preservation, the nuclei and 
outlines of the cells being sharply marked. In the more chronic 
lesions of the kidney the round epithelium appearing in the 
sediment is often fatty, the space between the nuclei and cell- 
walls being sometimes filled with oil-globules. The cells them- 
selves are often partly disintegrated or broken down, presenting 
a ragged appearance. These partly-disorganized cells may often 
be seen adhering to renal casts, or they may themselves become 
adhered together, forming casts. 

In chronic interstitial nephritis and uncomplicated amyloid 
disease of the kidneys but little desquamation from the renal 
tubules occurs, and in these cases the fewest round cells occur in 



ANATOMICAL SEDIMENTS. 187 

the urine. On the other hand, in acute scarlatinal nephritis the 
number of round epithelial cells in the urine is sometimes enor- 
mous. In acute congestive conditions of the kidney a very 
decided deposit of round cells are sometimes met with in the 
urine, without other pronounced changes in the latter save 
albuminuria. 

In pyelitis and diseases of the renal pelvis considerable de- 
posits of epithelium are met with, and in such cases, although 
round cells may be present, the tailed and spindle-shaped cells — 
columnar — are more apt to predominate. 

In cystitis there is more or less deposit of large flat epi- 
thelium. If the cystitis be of mild grade or largely confined to 
the superficial surface of the mucous coat of the bladder, the large, 
flat, irregular-shaped epithelium predominates, but in cj^stitis 
involving the deeper layers the large flat cells are more likely to 
be mingled with the columnar variety. 

URINARY CASTS. 

Urinary casts have always and very properly been regarded 
of the highest diagnostic value. They were probably first seen 
by Yigla and Rayer, but the able investigations of Henle and 
Rovida gave to the profession the most complete information as 
to their character and significance. 

Three chief views have been held as to their nature and mode 
of production : — 

First, that they are the result of disintegration of the epi- 
thelium of the renal tubules, the resulting products becoming 
packed into molds by the pressure of urine, until at length they 
slip through the smaller convoluted into the large straight tubes 
and appear in the urinary sediment. 

Second, that they consist of a secretion of the morbidly 
irritated epithelium lining the renal tubules, which become caked 
into molds and are washed down with the urine. 

Third, that they consist of coagulable elements of the blood 
which gains access to the renal tubules through pathological 
lesions of the latter, and that any free or partly-detached prod- 
ucts of the tubules become entangled in this coagulable product, 



188 ANALYSIS OF URINE. 

assisting to form the molds of the tubules, which subsequently 
appear in the urine as casts. 

The last view is the one most generally accepted, at least so 
far as the nature and origin of the great majority of casts are 
concerned. 

Although the substance forming the basis of casts is evi- 
dently closely allied to proteicls, } T et it is certain that it is not 
identical with any proteid with which we are at present familiar ; 
perhaps it is a derivative thereof. Rovida claims for hyaline 
casts the characteristic of being soluble in dilute mineral acids. 
Renal casts have been variously classified, but the most useful 
division for clinical study is as follows :— 

1. Those consisting of anatomical elements such as epithelial 
cells, blood- and pus- corpuscles. 

2. Those consisting of the products or broken-down elements 
of anatomical substances. 

3. Those clear casts often termed " hyaline" the nature of 
which, as well as is their origin, is still a disputed question. 

The first division naturally includes those casts largely made 
up of (a) red blood-corpuscles, (6) leucocytes, (c) epithelial cells, 
(d) masses of bacteria. 

The second division comprises (a) granular casts, (b) fatty 
casts. 

The third division comprises (a) narrow hyaline casts, (b) 
broad casts, (c) composite casts or those largely clear, but more 
or less coated with the elements enumerated in the first and 
second divisions, such as blood, pus, epithelium, fat, etc. 

Blood -Casts. — These appear in the urine under conditions 
which give rise to haemorrhage within the urinary tubules. 
Under the microscope they often appear as very beautiful objects. 
The perfectly-preserved corpuscles may be observed glued to- 
gether in perfect molds of the tubules, being usually short, of 
pretty uniform diameter throughout, and with rounded ends. 

These casts are met with in the urine in hematuria, acute 
diffuse nephritis, acute renal congestion, and haemorrhagic in- 
farctions of the kidneys. Blood-casts do not in themselves 
furnish positive evidence of organic renal disease, since any 
haemorrhage of the kidney may have associated therewith blood- 






ANATOMICAL SEDIMENTS. 189 

casts in the urine. On the other hand, it may be stated that the 
presence of blood-casts in the urine constitutes the only positive 
evidence of the existence of renal haemorrhage. Blood-casts 
may be considered as belonging to the rarer forms of renal casts 
found in the urine, and they are usually difficult to find, since a 
large sediment of free blood-corpuscles usually accompanies 
them, which greatly obscures the microscopical field. 

Epithelial Casts. — These result from pathological conditions 




Fig. 23.— Epithelial Casts. (After Peyer.) 

which cause exfoliation of the epithelium of the renal tubules. 
Sometimes the epithelial lining of the tubules is thrown off intact 
for short distances, resulting in epithelial cylinders which possess 
lumens. The epithelial cast also occurs in a solid form, the 
body being made up of hyaline substance and the surface covered 
with epithelial cells. These cells, as viewed under the microscope, 
appear more or less swollen and granular, with ill-defined margins. 
In some cases the epithelial cells appear in rows or in patches 
over the surfaces of the casts (Fig. 23). In other cases the 



190 ANALYSIS OF URINE. 

epithelial cells have partly undergone degeneration or contain 
dotlets of fat. These are significant of chronic or, at least, fatty 
changes in progress in the kidney. Finally some casts are to 
be seen which are entirely composed of epithelial cells aggluti- 
nated together. Epithelial casts are usually of medium size and 
length, refracting light to a comparatively high degree, and are 
therefore easy to discover in the microscopical field. They resist 
the action of chemical reagents to a greater degree than most 
other casts, except those that are partly metamorphosed. The 
presence of epithelial casts in the urinary sediment may be taken 
as a positive evidence of inflammation in the anatomical struct- 
ures from whence they originate ; and they are consequently 
sediments of the highest diagnostic value. 

Pus-Casts. — Casts composed exclusively of pus-corpuscles 
are exceedingly rare. Not infrequently, however, compound 
casts are met with, composed of epithelium or granular matter, 
in which scattering pus-corpuscles may be seen dotted over their 
surfaces. Johnson has described and illustrated casts entirely 
composed of pus-corpuscles which came from subjects who sub- 
sequently died of multiple abscess of the kidneys. Such casts, 
however, have rarely been noted by other observers. 

Bacterial Casts. — It is no rare occurrence to meet with casts 
in the urine which are composed of masses of micrococci. In 
appearance they closely resemble the dark granular casts, but 
they are readily distinguishable from the latter by their resist- 
ance to such chemical agents as strong mineral acids and caustic 
alkalies. They are more opaque than other casts, of a grayish 
color, and are uniform and very fine in their outlines. The use of 
high microscopical powers will render confusion in distinguishing 
these casts almost impossible. The discovery of casts in the 
urine made up of bacterial masses must be taken as a factor of 
very grave significance, since they are chiefly found in septic 
forms of nephritis often accompanied by embolism. They occur, 
therefore, in interstitial suppurative nephritis or ascending pye- 
lonephritis. 

Granular Casts. — This form of renal cast comes under the 
second division named, being the result of metamorphosis of 
anatomical elements, usually of epithelium, pus, or blood. Granu- 



ANATOMICAL SEDIMENTS. 191 

lar casts are found in the urine in great variety, as is shown by 
the terms frequently employed to designate them, such as finely 
granular, coarsely granular, granular, highly granular, moder- 
ately granular, light granular, dark granular, etc. 

Granular casts vary much in size and shape, as well as in 
appearance. They are most often met with in fragmentary 
forms, only occasionally preserving their entirety or perfect 
forms. They are irregular both in their coarse and fine outlines, 




Fig. 21— Granular Casts. (After Peyer.) 

and their ends are usually ragged, as if recently fractured. The 
granulations are often exceedingly fine, requiring high powers to 
distinguish them ; while, again, they are coarsely granular, which 
is apparent with comparatively low powers (Fig. 24). They are 
of various colors, as yellowish, white, gra}^, and brown. They 
may have scattered over their surfaces epithelium, leucocytes, fat- 
globules, or fatty crystals. Granular casts have generally been 
regarded as indicative of pathological conditions of the kidneys 
of chronic or degenerative character. 



192 



ANALYSIS OF URINE. 



Fatty Casts. — It has already been stated that fatty elements 
are sometimes seen mingled with the elements of epithelial casts, 
and the same may be said with regard to grannlar and many 
other forms of casts. But, in addition to these, highly-refracting 
casts are often met with in the urine, whose surfaces are com- 
pletely studded over with fatty globules and, less often, with fine, 
needle-like, fatty crj^stals (Fig. 25). Fatty casts are the result 
of a different form of transformation of anatomical elements from 




Fig. 25.— Fatty Casts. (After Peyer.) 



the last described. They constitute the index of fatty changes 
in the kidneys, and are found in their most typical form in 
''large white kidney." They may be looked upon as evidences 
of pathological states of the kidney, the chief feature of which 
is extreme chronicity, since they are probably the result of com- 
plete destruction of the cell-protoplasm, which becomes replaced 
by fatty elements. 

Hyaline Casts. — These are pale structures of variable but 
usually considerable length, sometimes very difficult to detect in 



ANATOMICAL SEDIMENTS. 193 

the sediment (Fig. 26). Sometimes they exhibit no granulation 
whatever upon their surfaces, being, in fact, almost transparent. 
Much more frequently, however, they exhibit very fine granula- 
tion of a very light color. They may exhibit here and there a 
dotlet of oil or a fragment of epithelium upon their surfaces, 
and, indeed, this is usually the case, although such casts are 
considered strictly of the hyaline order. 

With regard to the origin of hyaline casts, much difference 




Fig. 26.— Narrow Hyaline Casts. (After Peyer.) 

of opinion has prevailed. Oertel contended that they were the 
result of secretion from the epithelial cells of the renal tubules, 
and in this opinion he was supported b}^ Rovida. Bartels, on 
the other hand, holds that these casts are formed by a coagula- 
tion of the albumin or its derivatives excreted with the urine. 
As evidence of this, he states that they are only present in urine 
that is albuminous, or that has very recently been albuminous ; 
for the occurrence of albuminuria and casts are not always 
simultaneous. 

13 



194 ANALYSIS OF URINE. 

While the origin of the hyaline casts is not at present so 
clearly understood as most of the other forms, it is probable 
that they are formed by coagulable elements of the blood, which 
has gained access to the renal tubules. The experiments of 
Ribbert upon animals indicate that hyaline casts may result 
directly from exudation of albumin into the tubules ; and their 
disappearance from alkaline urine upon standing further indi- 




Fig. 27.— So-called "Waxy Casts. (After Peyer.) 

cates their close relationship to albuminous bodies, as long since 
demonstrated by the author. 1 

Numerous observers have claimed to have found hyaline casts 
in non-albuminous urine, but the author agrees distinctly with 
Bartels in that he has never met with them save in albuminous 
urine or urine that has recently been albuminous. 

The disposition by some to regard hyaline casts of the small, 
narrow order as of no serious import is a mistake of the gravest 
character, for, indeed, they are often the chief evidence, so far as 

1 Journal of the American Medical Association, September 12, 1885. 



ANATOMICAL SEDIMENTS. 195 

the urine is concerned, of the existence of a most serious form 
of renal disease, viz., interstitial nephritis ; for it should be re- 
membered that in such cases albuminuria is nearly always small 
in quantity. 

In addition to narrow hyaline casts which doubtless come 
from the smaller tubules within and above the middle zone of 
the kidney, the urine often contains large, broad hyaline casts, 
evidently emanating from the large, straight tubes of the pyra- 
mids. As a rule, these larger, clear casts are more refracting, 
and consequently more distinct both in body and outline than 
the narrow casts. They are also more iudentated at their mar- 
gins, although pretty uniform in their dimensions. There is a 
form of hyaline cast, usually of large size, that occasionally — not 
always — exhibits the characteristic amyloid reaction with methyl- 
violet and iodo-potassic iodine solutions. They are large and 
usually rather long, and their surfaces may be marked by inden- 
tations showing imperfect vertical segmentations, — " tape-worm 
form" (Fig. 27). The term waxy as applied to these casts is 
inappropriate. It was formerly thought that these casts were 
characteristic of amyloid changes in the kidneys, but more ex- 
tended observations have shown that they are found in all forms 
of nephritis. " These casts may exhibit the amyloid reaction in 
the absence of amyloid kidneys, or they may fail to exhibit it 
when amyloid disease of the kidney is present, and therefore no 
diagnostic value can be attributed to the reaction, save, perhaps, 
as indicating degenerative changes in the casts themselves " 
(Roberts). These casts are of comparatively rare occurrence. 

Cylindroids. — In addition to the casts described, the urine 
sometimes contains the so-called cylindroids of Thomas, who first 
observed them in the urine in a case of scarlatina. These are 
long, wavy, ribbon-like structures, which often divide and sub- 
divide at their ends with diminishing diameters. These ends 
may be folded or twisted in corkscrew form. They are pale, 
colorless, and of greater length than the ordinary casts described, 
and rarely, if ever, have attached to them any cellular elements 
whatever. They appear fiat and do not give the impression, to 
the eye, of being solid structures like true renal casts. It seems 
not improbable, however, that these cylindroids come from the 



196 ANALYSIS OF URINE. 

renal tubules. The} r occur in nephritis, cystitis, and renal con- 
gestion, and may be present in urine that is free from albumin. 
They are not characteristic of kidney disease, but probably more 
often caused by irritation of the lower urinary tract, which has, 
in a measure, extended to the kidneys. 

Lastly, it may be stated that casts are sometimes met with in 
the urine composed of urinary crystals or granular salts. Only 
those composed of urates and haematoidin have thus far been 




Fig. 28.— False Casts. (After Peyer.) 

observed, and they are of little practical significance, being only 
found in the urine of infants, or in cases of gout, renal conges- 
tion, etc. 

Method of Searching for Casts. — Since the more recent 
methods of obtaining the urinary sediment by means of the 
centrifuge, we no longer encounter the obstacles which were 
often very annoying and sometimes almost impossible to sur- 
mount in making a satisfactory microscopical inspection of the 
urine. The obstacles referred to especially were the following : 



ANATOMICAL SEDIMENTS. 191 

(a) The difficulty often encountered in getting casts to settle 
in urines of high specific gravity, because renal casts are of 
comparatively light weight and often float in such urines for 
hours without subsiding, (b) The changes in the urine upon 
standing often altered the essential features of the deposit, as 
before stated, sometimes rendering them unrecognizable, (c) In 
urine which stood long enough to secure the sediment, the micro- 
scopical field sometimes became so crowded with micro-organisms 
that the organic products were completely obscured from vision. 
Happily, these difficulties are now matters of the past ; and it is 
only necessary to secure a freshly-voided sample of urine, submit 
it to the centrifugal apparatus for two or three minutes, and we 
have a true and unaltered sediment, that exactly represents the 
pathology of the urine as it leaves the urinary tract. 

The urinary sediment obtained— always preferably by the 
centrifuge — is best examined in a shallow cell, upon a glass slide 
carefully covered with a cover-glass. This is best secured by 
taking up about 4 to 6 drops of the sediment in a nipple-pipette 
from the bottom of the sediment-tubes of the apparatus, and 
placing them upon a carefully-cleaned slide, then placing the 
cover-glass over the cell, and with the thin, freshly-torn edge of 
a piece of blotting-paper removing the excess of urine, which 
tends to spread over the cell and along the slide. By this means 
the sediment constitutes a temporary mount, so that it may be 
examined at any angle without flowing out of the cell. The slide 
is next placed under the microscope, which is adjusted with a 
J-inck objective for ordinary search, and examination conducted 
in a clear, but not too bright, light. 

The greatest difficulties encountered in searching for casts in 
the urine will usually be met with in the case of narrow hyaline 
casts. These bodies are so transparent and non-refracting that 
they are exceedingly liable to be overlooked. This may often be 
avoided by proceeding as follows : After securing an accurate 
focus of the field by careful regulation of the fine adjustment of 
the instrument, gradually darken the field by the mirror-adjust- 
ment and throw the light obliquely across it, illuminating the 
field, in fact, but about one-half or two-thirds its extent. Next, 
by slowly moving the slide about, the different features of the 



198 ANALYSIS OF URINE. 

sediment are presented to view in different lights, and the outlines 
or shadows of fine hyaline casts will often be brought into view, 
when they would be perfectly transparent and unobservable in a 
more direct reflection of sharp light. Once the outline is seen, 
by careful re-focusing the cast often stands out with distinctness. 
If doubts remain as to its true nature, by depressing both ends 
of the slide with the finger-tips currents will be created in the 
urine beneath the cover-glass (if mounted as directed), so that 
the cast will be made to move and even roll over, which will often 
settle any question as to its nature. The author has not found 
it necessary to treat these casts with staining agents to bring 
them into view, although this may be practiced successfully. It 
is, however, preferable, if possible, to view the microscopical de- 
posit, and especially renal casts, as nearly as possible in their 
native state, for obvious pathological reasons. 

Spermatozoa. 

Spermatozoa are thread-like bodies provided with a head and 
a long, tapering, tail-like extremity. The head is of a flattened 
oval shape with a central depression on either side. The head 
and tail are united by an intermediate, cylindrical-form body or 
neck of uniform size. The entire length of a spermatozoon is about 
? J n inch. When freshly ejected with the spermatic fluid sperma- 
tozoa exhibit active, eel-like movements, as though endowed with 
separate life, and under favorable circumstances — warmth and 
moisture — they long retain this capability. These movements 
may be observed in the body for several days after death, and in 
the uterine secretion longer than a week. The cause of the 
movements in spermatozoa is unknown, though it has been con- 
tended that they are mere floating cilia. Acid liquids stop these 
movements immediately, as do strong alkalies, especially ammo- 
niacal liquids ; also distilled water, alcohol, ether, etc. Sperma- 
tozoa show great resistance to chemical reagents. They do not 
dissolve completely in sulphuric acid, nitric acid, acetic acid, nor 
in boiling-hot sodium solutions ; but they are dissolved in boiling 
potassium-hj'drate solution. They resist putrefaction, and after 
drying they may be obtained again in their original form by 
moistening them with a 1-per-cent. sodium-chloride solution. By 



ANATOMICAL SEDIMENTS. 199 

careful heating and burning to ash the shape of these bodies are 
said to be seen in the ash (Hammarsten). 

As found in the urine spermatozoa are nearly alwaj^s in the 
quiescent state, and they may be found in the urine which has 
stood for days, their typical form being well preserved (Fig. 29). 

Clinical Significance. — Spermatozoa are only found in semen 
or fluids mingled therewith. Their persistent absence from 
seminal fluid indicates sterility or incapability of procreation. 




Fig. 29.— Spermatozoa in Urinary Sediment. (After Peyer.) 

Spermatozoa may be found in the urine after every ejaculation 
of seminal fluid, and therefore they may aid the physician in de- 
tecting masturbation. Spermatozoa are found in the urine in 
some cases of severe illness, such as typhoid fever, typhus pneu- 
monia, and after epileptic attacks. A very constant deposit of 
spermatozoids in the urine constitutes an essential feature of 
spermatorrhoea. In such cases the urine often shows the presence 
of white flakes, which under the microscope appear as masses of 
spermatozoa and finely -granular matter. 



200 analysis of urine. 

Fragments of Tumors. 

Contrary perhaps to general belief, fragments of new growths 
are rarely met with in the urine, and those that are occasionally 
encountered nearly always originate in the bladder. Small 
polypi have been found in the urine a few times, as well as frag- 
ments of villous growths. More often, perhaps, carcinoma of 
the bladder parts with some of its constituents, which subse- 
quently appear in the urine. In such cases the fragments are 
usually necrotic, and therefore practically impossible to recognize. 
The typical villous growth appears in its finest subdivisions as 
characteristic, tree-like branches — " fringe-like " — which consist 
of enlarged vessels covered with a single layer of epithelium ; but, 
owing to the necrotic changes resulting in their disintegration, 
these fragments are seldom seen in the urine in typical form. 
The epithelium has usually undergone molecular degeneration, 
accompanied by bacterial life, and the villus itself is infiltrated 
with the products of suppuration. It is only occasionally that 
forms are met with which assist in diagnosticating villous 
growths. Thus, crystals of hsematoidin may be observed in the 
necrotic masses, or they may be brought out frequently by 
treating the masses with glycerin. They may be recognized by 
their brownish-yellow color ; small, rhomboidal form ; or yellow, 
grass-like tufts. Treated with nitric acid and observed under 
the microscope, the well-known play of rainbow colors reveals 
the presence of biliary coloring matters. Since hsematoidin 
occurs in the urine only in isolated crystals, it follows that, if 
found imbedded in necrotic masses, it goes far to establish a 
diagnosis of cancer, since such conditions are only found with 
such growths (Jaksch). Hsematoidin villus is rarely recognized 
save in acid urine, because in alkaline urine the villous tissue is 
more disintegrated and mixed with phosphatic deposits. 

Cancer of the kidney can rarely, if ever, be diagnosticated 
from the nature of the anatomical sediments in the urine. The 
transitional epithelium, more or less abundantly present in all 
inflammatory conditions of the urinary tract, simulates so closely 
those of cancer that it is never safe to draw any positive conclu- 
sions as to the presence of cancer from this source. It is only 
when considered in connection with other symptoms, such as 



ANATOMICAL SEDIMENTS. 201 

haemorrhage, pain, cachexia, etc., that a positive diagnosis may 
usually be reached. 

BACTERIURIA. 

It has been generally accepted that healthy urine when freshly 
voided is free from bacteria, and is, in fact, an aseptic fluid. 
Over thirty 3 T ears ago Pasteur demonstrated that such urine is 
sterile, and this has been repeatedly confirmed since. If, how- 
ever, the ordinary normal urine be allowed to stand for some time 
at ordinary temperatures it becomes crowded with micro-organ- 
isms. This is due to the fact that the urine contains so large a 
percentage of organic matter that it practically constitutes a 
culture medium for many forms of these organisms. 

Abnormal urine nearly always contains micro-organisms, of 
which nearly forty varieties have been 

isolated to date. They practically all <^P j^^^ 

belong to the class of fungi, and for 
purposes of study may be divided into 
two classes, viz. : (a) non-pathogenic 0q Sf° ccD ° 

fungi, or those which are innocuous, ^ ° cC ° 

and (b) pathogenic fungi, or those q ° « 



possessed of pyogenic powers. o m ^j® 

Non-pathogenic Fungi. — These in- ® ® ® •"" 

elude mo Ids, yeasts, and fission-fungi. • %<§k° o 

Molds are of comparatively rare fig. 30.— Ykast-fungus in 
occurrence in urine, even when under- Urine. (After Hariey.) 
going ordinary decomposition ; but if 

diabetic urine be allowed to undergo alcoholic fermentation, at 
its conclusion molds make their appearance in quantities upon 
the surface of the urine, which also becomes crowded with 
yeast-fungi. 

The yeast-plants of the urine (saccharomyces urinae) are 
single cells of about the size of blood-corpuscles. The} r are dis- 
tinguishable from blood-cells by the irregular and occasionally 
large size of the cells, the presence of a nucleus in the larger 
sporules, and their more elongated or oval form. Usually these 
cells are arranged in bead-like forms, some of the beads having 
several small bud-like cells attached to them (Fig. 30). For their 
development it is necessary that the urine be distinctly acid, and 



202 



ANALYSIS OF URINE. 



they cease to multiply if the urine become alkaline. The pres- 
ence of yeast-fungi in the urine in large numbers may be taken as 
certain evidence of the presence of sugar. 

Fission-fungi are associated with urine tending toward putre- 
factive changes. Such urine is more or less cloudy when voided ; 
it is never sharply acid ; on the eontraiy, it is usually neutral in 
reaction or feebly alkaline. Examined under the microscope it 
is seen to be crowded with micro-organisms in active motion, 
such as the more common forms in decomposing organic fluids, 
the most familiar being the well-known bacterium termo. The 
urine on standing does not clear, and, moreover, it does not clear 
by filtration, and it tends to rapidly pass on into ammoniacal 
decomposition. This condition of urine is 
most often met with in weakly and en- 
feebled people, and in men who have 
urethral stricture, or who have frequently 
had catheters or bougies passed. In the 
process of ammoniacal fermentation of 
the urine, urea is transformnd into ammo- 
nium carbonate through the agencj^ of 
bacterial life. To each molecule of urea 
two molecules of water are supplied, and 
the chemico-vital change wrought by 
bacterial activity results in two molecules 
of ammonium carbonate. The chief agent concerned was 
formerly believed to be the micrococcus ureae, as almost pure 
cultures of this organism are often observable upon the surface 
of the decomposing urine. It has recently been shown, however, 
that nearly all microbes found in the urine possess the above 
powers to a greater or less extent. The micrococci ureae are 
organisms of comparatively large size, and are most frequently 
observed in long, chain-like strings ; although they also occur 
as free and independent, minute, round objects (Fig. 31). 

Ammoniacal bacteriuria is most frequently met with in cases 
of obstructive cystitis, in which more or less residual urine 
remains in the bladder, as often results from paraplegia or 
enlarged prostate, and urethral stricture of small calibre. The 
frequent use of instruments in the urethra and bladder often 
results in this condition. 




Fig. 31. — Micrococcus 
Ure.e. (After v. Jakscli.) 



ANATOMICAL SEDIMENTS. 203 

In addition to the micrococcus urese, the urine may contain 
various other forms of non-pathogenic fungi, including rod-like 
bacteria of various forms and sizes. Occasionally long, spiral 
bacilli, with large spores and cocci, are met with in the urine. 
These are often grouped in various-shaped masses, usually of 
dark color and variable sizes. For the most part, these organ- 
isms gain access to the bladder through the urethra. This may 
take place through discharges or, more commonly, by the use of 
instruments. 

Pathogenic Fungi. — The pathogenic bacteria found in the 
urine for the most part belong to two orders, — viz., micrococci 
and bacilli. 

The micrococci found are those characteristic of suppurative 
diseases in general, and include the staphylococcus pyogenes albus, 
aureus, citreus, and the streptococcus pyogenes. The action of 
these germs is general, which accounts for their frequent presence 
in the urine. To these must be added the gonococcus of Neisser, 
which will be considered later. 

The bacilli met with in the urine include the urobacillus 
liquefaciens septicus, the bacillus coli communis, the tubercle 
bacillus of Koch, besides a number of others less well known. 

In all infective diseases in the healthy organism, if life be 
not destroyed thereby, the microbes must either be destroyed in 
the blood and tissues by the process termed phagocytosis, or be 
eliminated through the excretory organs, usually in an active 
state. The fact of the rapid disappearance of most micro- 
organisms from the blood, when injected into the circulation of 
the healthy organism, indicates that the corpuscular elements 
of the blood have the power of destroying these organisms, — at 
least, to a large extent. Passing from the blood into the tissues, 
these organisms meet with the same warfare in the tissue-cells. 
Should, however, both of these sources of phagocytosis prove 
unsuccessful in destroying these organisms, there still remains a 
method by which the unassisted organism may rid itself of these 
microbes, — viz., by means of elimination through the excretory 
channels ; and in this process the kidneys and intestinal canal 
are the chief organs concerned. The frequency with which the 
kidneys become infected in the course of general tuberculosis 



204 ANALYSIS OF URINE. 

furnishes proof that these organs are the source of elimination 
of tubercle bacilli. Furthermore, Philipowicz has succeeded in 
producing tuberculosis in animals hy injecting urine into the 
peritoneal cavity which was taken from tuberculous subjects. 

Neumann has demonstrated the characteristic microbes of 
typhus, pneumonia, and pyaemia in the urine in the course of 
these diseases, and he has cultivated from the urine, in acute 
endocarditis and osteomyelitis, the staphylococcus pyogenes 
aureus. Neumann furthermore claims that the microbes which 
gain access to the circulation often localize in the capillary 
vessels of the kidney, there causing multiple lesions without in- 
volving the whole organ; and through these lesions some of the 
microbes gain access to the uriniferous tubes and appear in 
the urine. 

Schweiger has conclusively demonstrated that the urine of 
scarlatinal subjects is distinctly contagious ; and he regards all 
renal lesions arising in the course of infectious fevers of microbic 
origin. Finally, it may be mentioned that Rimann has conclus- 
ively demonstrated the passage of bacilli through the kidneys 
in the following manner : The bacilli discovered in the pus of 
ozsena was cultivated in gelatin and agar and stained intensely 
green ; after dilution with physiological solution of salt, the 
culture was injected directly into the circulation of a dog, cat, 
and rabbit ; after a time these stained microbes appeared in the 
urine in large numbers. 

Of the various pathogenic micro-organisms found in the 
urine, the recognition of the bacillus tuberculosis of recent years 
claims the greatest clinical interest. It may be stated that the 
presence of this bacillus in the urine, especially when arranged 
in S-shaped aggregations, or in colonies of irregular masses, 
points with unmistakable certainty to tubercular ulceration of 
the urinary tract. Fortunately for diagnostic purposes, if the 
tubercle bacillus appear in the urine at all, it usually occurs in 
abundance, and may, with recent methods, be recognized in 
masses often arranged as in pure cultures. 

In all cases of purulent urine accompanied b}^ anaemia, wast- 
ing, and evening temperature, the urinary sediment should be 
examined for the presence of tubercle bacilli. Of course, more 



PLATE VII. 









Tubercle Bacilli in Urinary Sediment. 
(After v. Jakscli.) 



ANATOMICAL SEDIMENTS. 205 

patient search is necessary than in the examination of sputa, 
owing to the dilution of tubercular pus by the urine, and it is 
necessary to concentrate it as much as possible for the same 
reasons. This is best accomplished by the centrifuge for obvious 
reasons. The purulent deposit of tubercular urine should be 
treated precisely as the sputum in searching for tubercle bacilli. 
Should difficulties be encountered in finding the bacilli when the 
symptoms strongly point to their presence, or should doubts 
arise as to the true character of the bacilli found in the urine in 
any given case, the inoculation of animals with the sediment 
or plate cultures thereof should be resorted to before negative 
conclusions can be positively reached. Indeed, unless the time 
required for the latter be a matter of importance in the case 
(which is very seldom), the plate cultures are the easiest and 
most certain method of success. 

Gonococci were first discovered in the pus of gonorrhoea by 
Neisser. They consist of minute, roll-shaped cocci. They are 
chiefly met with as diplococci, the individual cocci being seem- 
ingly divided by a bright, transverse band, often presenting the 
so-called " roll-form" ; also termed " kidney- " or " bean- " shape. 
The cocci usually appear in pairs lying close together, their flat- 
tened surfaces usually presented to each other. They multiply by 
each coccus splitting in two. Bodies in all respects resembling 
gonococci, so far as present methods are able to determine, have 
been found in the genital tract under the most variable conditions, 
and this fact has tended greatly to diminish the diagnostic value 
of these organisms. On the other hand, it is pretty well estab- 
lished that the presence of gonococci within pus-cells in purulent 
urethritis is characteristic of infective gonorrhoea. In all cases 
of recent infection with gonorrhoea the specific gonococci are to 
be found within the pus-cells in abundance, although they are 
not limited to this location, but may be seen in the epithelia, as 
well as floating in the liquor puris. This cannot be said of the 
non-infective forms of diplococci. The gonococcus is best stained 
in gentian violet, methylene blue, or fuchsin, after which it may 
be rinsed in water and examined under the microscope. 



206 ANALYSIS OF URINE. 

VERMES. 

Distoma Haematobium. — This parasite has frequently been 
found in the portal vein and its branches, in the splenic and 
mesenteric veins, and in the venous plexuses of the bladder and 
rectum (Fig. 33). From the investigations of Bilharz, it would 
seem that more than half the adult Fellaheen and Coptic popu- 
lation of Egypt suffer from this parasite. 

The eggs of this parasite are found in numbers in the urinary 
passages and in the urine. They are usually accompanied by 
blood, pus, and sometimes by considerable fat. The eggs are 
oval, flask-shaped bodies, with rather sharp projections from 




Fig. 32.— Eggs of Distoma from Urinary Sediment. 

their anterior extremities. They measure rather less than ¥ J^ 
inch in length. 

When confined to the larger veins, these parasites do not pro- 
duce much damage ; but if they invade the smaller vessels, 
notably those of the submucous tissues of the urinai^ tract, they 
induce severe and, in some cases, fatal consequences. In the 
intestines the result is often that of severe d} T sentery. 

The most serious results of the raA^ages of this parasite are 
met with in the urinary passages. The lesions produced here, 
according to Griesinger, consist of raised patches of injected 
and ecclrymosed tissue, which often pass into ulcerations, giving 
rise to severe haemorrhages. These patches are covered with 
mucus and brownish exudations of bloody matters containing 
masses of ova. If no lesions of the mucous membrane occur 



ANATOMICAL SEDIMENTS. 207 

over these patches, they may remain as nodules of more or less 
firm and indurated tissue. 

When these parasites invade the ureters and renal pelvis, the 
results are apt to be still more serious, as they threaten the in- 
tegrity of the kidney from two sources. First, by consequent 
thickening they may cause occlusion of the ureters and resulting 
hydronephrosis or pyonephrosis, as in a case observed by Grie- 
singer. Second, severe pyelitis is often set up by invasion of the 
renal pelvis, which may result in ascending pyelonephritis. 

In addition to these consequences the masses of ova extruded 
into the urinary passages are exceedingly liable to become the 
nuclei for urinary calculous formation ; and, indeed, this is claimed 
to constitute the cause of the great frequency of calculous dis- 
ease in Egypt. 

From the variety of lesions caused by invasion of the Distoma 




Fig. 33.— Distoma Haematobium, Male and Female, with Eggs. 

haematobium, as might be expected, a corresponding variety of 
clinical symptoms result. In the milder cases but little dis- 
turbance of the urinary function is to be observed. Some pain, 
described as of a burning character, is notable on micturition. 
This, however, is but momentary, and is chiefly due to the pass- 
age of the ova along the urethra, which they irritate by means 
of their sharp projections. At the termination of micturition a 
few drops of blood, or a blood-clot, are sometimes noted. The 
urine contains pus and blood-cells, with the eggs of the parasite 
as represented in Fig. 32. The symptoms become more dis- 
tressing with the involvement of the bladder, entailing various 
grades of cystitis, always accompanied by more or less hsema- 
turia. To these may be added the discomforts and deterioration 
of the general health entailed by pyelitis when the parasite in- 
vades the renal pelvis. Septic infection, nephritis, and uraemia 
are among the most serious consequences entailed by extension 



208 ANALYSIS OF URINE. 

of the morbid changes set up by the parasite in the upper urinary 
tract. Finally, it may be noted that Bilharz and Griesinger, 
during the course of their investigations in Egypt, found strong 
evidence that the distoma disease sometimes takes the course of 
an acute and rapidly fatal disorder. Griesenger observes : " We 
found on two occasions, in the bodies of persons who had rapidly 
died from an unknown acute disease, abundant recent distoma 
changes in the bladder, recent p3 T elitis, and a uniform dark-red 
hyperaemia of the kidneys. In other cases of supposed rapid 
typhus the same changes were found in the bladder and ureters." 



BSv* I % *£.-■ i I * a ■ ^ - lap 

Kt* ;: ' %>- ■ \^W " ®& M * : #- 

Fig. 34.— Filaria in Human Blood. (After Mackenzie.) 

Filaria Sanguinis Hominis. — Dr. Lewis, of Calcutta, was the 
first to describe this parasite as occurring in the human organism. 
In 1872 Lewis made the interesting announcement that, as ob- 
served in India, chj^lous urine always contained large numbers 
of these parasites. He later on discovered that these worms 
were present in great numbers in the blood of patients suffering 
from chyluria. This hsematozoon is about the width of a red 
blood-corpuscle and about fifty times longer than its width. It 
possesses a short, rounded head, with a tongue-like protuberance, 
and a rather long and pointed tail. The parasite is inclosed in 
a loose sac, in which it moves with freedom. This covering 



ANATOMICAL SEDIMENTS. 209 

appears structureless, but the parasite itself, as viewed under 
the microscope, is seen to be very granular, with transverse 
striations. 

It was early supposed that the minute hsematozoon described 
and figured (Fig. 34) was but the young of a larger, parent worm, 
and in 1816 Bancroft, of Brisbane, succeeded in demonstrating 
the mature worm in a lymphatic abscess of the arm. The 
mature form is a nemotode worm, about the thickness of a hair 
and three or four inches in length. Dr. Mason has established 
the origin of this parasite in the mosquito, which deposits the 
larva in ponds, the water of which being swallowed, the subject 
becomes the seat of its further development. The most curious 
and interesting circumstance in reference to the habits of this 
parasite is the fact, pointed out by Mason, that the embryo 
filaria is very active at night, but quiescent during the day ; it 
is therefore to be found abundantly in the blood of subjects of 
this disease during the night, but not to be found during the 
day. Dr. Mackenzie observed, however, that upon reversing the 
order of sleeping and waking, the filarial changed their nocturnal 
habits, — coming out when the subject slept and remaining hidden 
during the waking hours. It would, therefore, seem that the 
activity of filarial in the blood depends upon quiescence of the 
subject. What becomes of the filarise, or where they conceal 
themselves temporarily during their disappearance, as yet remains 
a mystery. 

The filarise, though greatly obstructing the lymph-channels 
and literally swarming in the blood, of themselves do but com- 
paratively little mischief. The embryos appear to pass readily 
through the capillary vessels without causing obstruction, irrita- 
tion, or emboli. It is, however, altogether different with the ova 
if they remain unhatched in the blood, lymphatics, and the 
urine. Owing to their greater diameters, they become arrested in 
the smaller lymphatic vessels and, becoming impacted, accumu- 
late until the gland becomes impervious, resulting in lymphatic 
congestion and even necrotic changes ; elephantiasis, or lymph - 
scrotum, is one of the results of this condition. Chyluria is 
one of the most frequent consequences, also, of this condition. 
This is brought about through the obstruction of the larger 



210 



ANALYSIS OF URINE. 



lymphatics, the thoracic duct, or large channels between it and 
the urinary organs. 

Echinococci. — The hooklets and scolices of the echinococcus 
cyst are among the rarer forms of sediments met with in the 
urine (Fig. 35). It is exceptional for echinococci cysts to develop 
in the urinary passages ; more often the products of these cysts 




Fig. 35, 



-Echinococcus, with Two Hooklets and Section of Cystic 
Membrane Greatly Magnified. (After Peyer.) 



make their way into the urinary passages from the kidney or 
some neighboring organ by means of rupture. If the charac- 
teristic hooklets appear in the urine, they are usually accom- 
panied by blood, pus, and more or less cellular debris, as well 
as shreds of the membrane forming the C} T stic envelope. 

Echinococci are minute ovoid parasites barely visible to the 
naked eye. They consist of a head not unlike that of the tape- 
worm, provided with four mouths or suckers and a double row 
of hooks. The echinococci are developed within a germinal 
membrane, and exist in groups of from six to ten. The hydatid 



ANATOMICAL SEDIMENTS. 211 

growth consists of an outer, fibrous capsule by which it is 
attached to the organ in which it is developed. Within the 
capsule is the hydated cyst, which varies in size from that of 
a marble to that of a distended urinary bladder, or even larger. 
Within the large cyst a great number of secondary or so-called 
daughter-cysts develop and float freely in a serous or rather 
saline, aqueous fluid. These daughter-cysts also vary in size 
from that of an apple to minute points requiring the microscope 
for their recognition. The mother-cyst may, in rare cases, be 
entirely barren, — i.e., contain nothing but fluid, — or it may con- 
tain thousands of secondary or daughter-cysts. 

Siebold pointed out the interesting fact that the hydatid 
worm in man is the encysted form of development of a very 
minute tape-worm which infests several animals, notably the 
dog, pig, monkey, sheep, etc. This tape-worm is the Taenia 
echinococcus, and is very minute — about the size of a millet-seed. 
The intestines of the dog are usually infested with great num- 
bers of these worms. The eggs are discharged with the stools, 
and, finding their way into food, reach the stomach in man, 
where they find suitable conditions for their development. The 
embryo, upon hatching in the stomach, burrows its way or is 
carried by the blood to some organ, — most often the liver or 
kidneys, — where it develops as the hydatid vesicle, in which 
are contained the echinococci described. In Iceland, where the 
natives live with their dogs in huts, it is said that one-seventh 
of the deaths are due to the ravages of these parasites. 

Strongylus Gigas. — This nematode worm has been found in 
the renal pelvis of dogs, wolves, horses, oxen, and other animals, 
and less frequently in the human kidney. It somewhat resembles 
the Ascaris lumbricoides, but it has six papillae about the mouth 
instead of three, and it attains a much greater length, — one to 
three feet, — and it is nearly a quarter of an inch in thickness. It 
may further be distinguished from the common round intestinal 
worm by its reddish color. This parasite may be said to be 
peculiar to the kidney, being very rarely met with elsewhere. 
Leuckart has, after some research, questioned the appearance of 
this parasite in the human organism, but there is, beyond doubt, 
at least half a dozen well-authenticated cases on record, in 



212 ANALYSIS OF URINE. 

addition to a specimen in the Hunterian Museum, taken from 
the kidney of a patient of Sheldon's (Dickinson). 

In addition to the parasites described, ascarides have been 
found in the urine in exceptional cases. In such cases the worms 
have usually made their way from the lower intestines into the 
urinary tract, usually by way of abnormal openings. In cases 
of women, these thread-worms have made their way into the 
bladder through the urethra. 



SECTION VIII. 

GRAVEL AND CALCULUS. 

Concretions of a more or less hard and dense character are 
liable to form in the urinary passages. These bodies are va- 
riously termed, according to their size, location, etc., sand, gravel, 
stone, and calculi. These formations are called primary when 
they are deposited from urine which has undergone no decom- 
positional changes, and are the result of some original defect of, 
or foreign addition to, the composition of the urine. The sec- 
ondary formations, on the other hand, are due to decomposition 
of the urine with resulting precipitation of its elements, and, for 
the most part, comprises those ammoniacal changes of the urine 
resulting from inflammatory disorders of the lower urinary 
passages. Concretions of small size — not too large to make 
their way spontaneously through the urethra — have been some- 
what arbitrarily termed gravel ; while, on the other hand, the 
larger concretions have received the name of stones or calculi. 
Concretions vary greatly in size ; some of them being so minute 
as to require the microscope for their recognition, while others 
attain the enormous size of an orange or even larger. The 
smaller concretions mostly emanate from the kidneys or renal 
pelvis, while those of large size come from the bladder. 

The most practical classification of urinary concretions is 
that which corresponds to the chief constituents of which they 
are composed. This comprises the following divisions : (1) uric 
acid; (2) urates; (3) oxalate of lime ; (4) cystin ; (5) xanthin ; 
(6) urostealith ; (7) basic calcium phosphate ; (8) calcium car- 
bonate; (9) calcium phosphate with ammonio-magnesium phos- 
phate. These are all strictly of urinary origin, and composed 
of urinary ingredients. In addition to these, at least two other 
classes of concretions are met with, whose origin are extra- 
urinary, viz., prostatic calculi and fibrin or blood concretions. 

Concretions may consist exclusively of one ingredient, uric 
acid and calcium oxalate being the most frequent examples. 

(213) 



214 ANALYSIS OP URINE. 

Far more frequently, however, two or more primary deposits 
occur in separate and alternate layers, constituting the so-called 
" alternating " calculus, the most common of which are those com- 
posed of uric acid and calcium oxalate. The number and thick- 
ness of these layers in alternating calculi vary very greatly ac- 
cording to the age of the calculi and the frequency of the changes 
giving rise to the alternating deposits. The thickness of the 
layers also varies to some extent inversely with their number. 

If a calculus consist of but one primary substance, its arrange- 
ment is usually stratified, exhibiting a larger or smaller number 
of concentric layers. Such are usually uric-acid, calcium-oxalate, 
and phosphatic formations. The great majority of concretions 
consist of a central division or nucleus, and an excentric division 
or body. There may be in addition, especially in old or large 
calculi, an external envelope or crust, which is nearly always 
phosphatic. The nucleus varies much in size and composition. 
It may consist of the same material as the body of the calculus, 
especially when the latter is made up of such primary deposits 
as uric acid, calcium oxalate, etc. Frequently, however, the nu- 
cleus consists of some organic product, as blood-clots, coagulated 
mucus, or epithelium. Exceptional^ foreign bodies introduced 
from without into the bladder become the nuclei for subsequent 
calculous formations. 

The causes of urinary concretions comprise (a) the con- 
ditions favorable for their origination ; (b) the conditions favoring 
their formation and growth. The conditions favoring the origin 
of calculi have received some light through the researches of 
Carter, who found that the actual nucleus nearly always consists 
of globular forms of urates and calcium oxalate, rather than 
crystals of these substances; and, furthermore, that a colloid 
matrix was always an essential element of the nuclear formation. 
Rainey and Ord have furthermore shown that the globular forms 
of urates and oxalates referred to are only produced when pre- 
cipitation occurs slowly in the presence of a colloid medium. 
From this it would appear that morbid conditions of the urinary 
passages accompanied by exudations of colloid matter, such as 
mucus or albuminoids, constitute the initial step in the forma- 
tion of calculi. In the presence of such colloids precipitation 



GRAVEL AND CALCULUS. 215 

of urates, oxalates, etc., occurs, which, combining with the col- 
loids, form globular aggregations that constitute the basis for 
subsequent development of stone. The conditions favoring the 
growth and development of concretions embrace chiefly the 
states of the system or of the urine itself which favor precipita- 
tion of the urinary solids. Under the first set of causes may be 
mentioned digestive disorders, organic diseases of the kidneys, 
and diseases of the urinary passages, most notably cystitis. 
The conditions of the urine favoring the growth of calculi are 
variable, and in some cases directly opposite. Among these 
causes may be mentioned (a) excess in the urine of the precipi- 
tated substance ; (6) overacidity of the urine. This disposes 
more especially to the growth of uratic concretions, as it dimin- 
ishes the solvent powers of the urine over uric acid and the 
urates, thus leading to their precipitation, (c) An alkaline con- 
dition of the urine. This may lead to precipitation of the phos- 
phates or carbonates of calcium and magnesium. If the urine 
be alkaline from fixed alkali, the earthy phosphates or carbonates 
of calcium may be precipitated and favor calculous growth of 
that order, — a rare condition, however. If the urine be alkaline 
from volatile alkali — ammonia — the result is precipitation of 
triple-phosphate of ammonium and magnesium, — an exceedingly 
common occurrence, (d) Deficiency of urinary salines and of 
sodium and alkaline phosphates in the urine weaken its solvent 
powers over the urates and cause precipitation, (e) Lastly, 
deficiency of the normal urinary coloring matters greatly weakens 
its solvent powers and favors precipitation of various constitu- 
ents, especially uric acid and the urates. 

Uric- Acid Concretions. 
Calculi composed entirely or chiefly of uric acid comprise 
the great majority of stones met with in human urine. Sta- 
tistics give the proportion to all other forms at from 75 to 90 
per cent. Indeed, the great frequency of this form of gravel 
led early observers to the conclusion that all stones were com- 
posed of uric acid in whole or in part ; hence the name lithuria, 
for a long time, was applied to gravel in general, and even at 
the present time is sometimes erroneous^ applied. 



216 ANALYSIS OF URINE. 

Uric acid may be passed in the form of crystalline clusters, 
or as smooth, spherical bodies, ranging in size from a pin-point 
to that of a grain of wheat, or, again, in roughened concretions 
as large as a pea. These are derived from the kidney or renal 
pelvis, and may be washed out with the urine singly or in num- 
bers at different intervals. The passage of uric-acid gravel from 
the kidneys is usually attended by more or less pain, sometimes, 
indeed, so acute that it has received the name of " renal colic." 
All these uric-acid concretions present a yellowish-brown or 
reddish appearance. If retained in the bladder, these small 
concretions grow, more or less rapidly, into round or oval or 
elongated and flattened stones. Their surfaces are tuberculated 
and irregular, and they vary in weight from a few grains to four 
or five ounces. They are hard and brittle, and, upon section, 
they may be seen to be marked with concentric laminae. 

Uric acid may be recognized by the murexid test (see page 
33). It is soluble in solutions of lithium, potassium, and sodium, 
and also in piperazin, while in solutions of sodium and potassium 
bicarbonate it is insoluble, as well as in water and dilute acids. 
Since the combination of uric acid and lithium is more soluble 
in water than its combination with sodium or potassium, it has 
become popular to treat the so-called uric-acid diathesis with 
mineral waters containing a few grains of lithium carbonate to 
the gallon. As Bunge has shown, 1 however, " this naive idea 
simply implies ignorance of Bertholett's law in reference to the 
diffusion of bases in the economy, as no such solvent action of 
uric acid in the economy is obtained thereby." 

The formation of uric-acid calculi is most frequent in early 
and late life ; that is to say, in children and old people. A 
highly-acid state of the urine is the most essential condition for 
deposition of this form of concretion. Uric acid frequently 
forms the basis of calculi which, subsequently, becomes the 
nuclei for further formation with other urinary constituents, 
constituting mixed calculi. The most frequent of these second- 
ary formations is calcium phosphate ; less frequently, calcium 
oxalate. Should the urine become alkaline at any time from 

1 Text-Book of Physiological and Pathological Chemistry, London, 1890, 
pp. 356 and 357. 



GRAVEL AND CALCULUS. 217 

volatile alkali, triple phosphates will be deposited and add to 
the growth of the calculus. This, indeed, is almost an essen- 
tial in the late stages of calculous life in the bladder, since alka- 
line urine is one of the features of vesical inflammation which 
attends nearly all calculi of any size, especially during their late 
sojourn in the bladder. The conditions favoring the deposition 
of uric acid have been more fully considered in another section 
of this volume (page 32). 

Urate Concretions. 

Urates rarely constitute the sole constituent of stone in 
adults, but with uric acid the}^ are frequently met with in the 
calculi occurring in children. On the other hand, in connection 
with calcium oxalate, urates form a large percentage of calculi 
found. Urate concretions have been regarded as consisting of 
ammonium urate, but calcium and sodium are to be found in 
them quite generally upon analysis. They do not attain a large 
size, as in the case of uric-acid stones, rarely being found larger 
than a small marble. They are usually of a light-grayish color 
and multiple in number, two or more being found together. 
They are not so hard and dense as the uric-acid calculi. Like 
uric acid, urate stones are nearly always deposited from acid 
urines ; the exceptions to this rule consist chiefly of the mixed 
stones of triple phosphate and ammonium urate, which are the 
outgrowths of ammoniacal urine. 

The urate deposits possess a great tendency to form infarcts 
in the renal tubules during early infancy. These consist of 
ammonium and sodium urate, which form yellowish-brown lines, 
often reaching from the papillae to the bases of the pyramids, 
following the lines of and blocking the interiors of the large, 
straight, uriniferous tubes. They occur most frequently from 
the second to the tenth day after birth, although they may occur 
as late as ten or twelve weeks after birth. It is significant that 
these infarcts are not found in the kidneys of stillborn children. 
The conditions leading to these deposits in infants is physio- 
logical rather than pathological, — due to the highly-concentrated 
state of the urine at birth ; the deficiency of aqueous elements 
in the urine does not permit either of solution or washing out 



218 ANALYSIS OF URINE. 

of the uratic components of the urine, which, upon the establish- 
ment of respiration, become greatly in excess. 

In febrile conditions in children deposits of sodium urate 
are common, and no doubt frequently form the nuclei and pri- 
mary deposit for the subsequent development of gravel. The 
frequent occurrence of calculi in children may be largely attrib- 
uted to this source. 

Calcium-Oxalate Concretions. 

Oxalate of-lime concretions are met with most often as large, 
rough, dark, tuberculated masses commonly called " mulberry 
calculus" Less often they occur as small, rounded, smooth, 
dark-grayish bodies, called " hemp-seed " calculi. Calcium-oxa- 
late concretions are extremely hard and brittle, and when crushed 
present sharp, angular lines of fracture. The nucleus often con- 
sists of uric acid or urates, or it may be colloid. Pure calcium- 
oxalate calculi are often met with, but much more frequently 
mixed calculi of calcium oxalate and uric acid occur in alternating- 
strata around a mixed nucleus. Less often calculi are met with 
consisting of oxalate of lime as the basis, surrounded by a more 
or less deep incrustation of triple phosphate. 

The urine associated with calcium-oxalate calculi is always 
acid, unless in cases of long standing, in which the stone has set 
up cystitis, when it ma}^ be found ammoniacal. In short, the 
condition of the urine in these cases is very similar to that with 
uric acid, as might be expected from the fact that calculi are so 
often encountered composed of alternating layers of these two 
substances. 

Cystin Calculus. 

This form of concretion is comparatively rarely met with in 
practice. Although not usually attaining the large size of uric- 
acid calculi, they may be found in the bladder exceptionally of 
considerable dimensions. As a rule they are of medium size, 
oval or cylindrical in form, with finely-granular surfaces, over 
which may be seen small crystals of a decidedly yellow color. 
Although these concretions are rather soft and compressible, 
they break with a crystalline fracture. Upon section they pre- 
sent a radiated appearance of yellow color not unlike bees-wax, 



GRAVEL AND CALCULUS. 219 

but they turn gray upon exposure to light. The causes of cystin 
deposits in the urine have already been discussed in the pre- 
ceding section. The most notable feature in this connection is 
its tendency to occur repeatedly in members of the same family. 
Cystin is readily recognized by its ready solubility in ammo- 
nia, depositing, upon evaporation, its beautiful and character- 
istic six-sided crystals. It is also soluble in mineral acids as 
well as in the fixed alkalies and their carbonates ; while it is 
precipitated by vegetable acids and ammonium carbonate. 

Xanthin Concretions. 

Xanthin calculi are exceedingly infrequent ; in fact, they are 
perhaps the rarest of all concretions met with in the urine. 1 
They seem to be entirely confined to young subjects, none as yet 
having been met with either in adult or in advanced life. 

Xanthin concretions are of a whitish, yellowish-brown, or 
cinnamon-brown color, of medium hardness, with amorphous 
fracture, and on rubbing appear like wax. They vary in size 
from a pea to that of a hen's egg. They burn completely when 
heated on platinum-foil. They give the xanthin reaction with 
nitric acid and alkali, which should not be mistaken, however, 
for the murexid reaction. 

Calcium-Phosphate Concretions. 
Phosphate-of-lime calculi are among the rarer forms of un- 
mixed concretions. They possess a chalk-like appearance and 
break with an amorphous fracture. They may be dense in 
structure or loose and spongy. Two forms of calcium-phosphate 
calculi occur: (a) Round or oval-form, varying in size from a 
small bean to a hen's egg. These are of a white, chalky appear- 
ance, of friable surface, and break with an amorphous fracture. 
These are usually vesical calculi of elderly people, especially 
dyspeptic people with alkaline urine. (6) The second form are 
irregular, sometimes branched in shape, of a grayish-white color, 
compact in texture, brittle, and of porcelain-like fracture. These 
are usually found in cysts and pockets of the urinary channels, 
and appear to be of local origin. 

1 Less than a dozen cases are at present on record. 



220 ANALYSIS OP URINE. 

The earthy phosphates are often abundantly deposited in the 
urine, but, owing to their amorphous form, they possess little 
tendency to concrete; otherwise this form of calculus would 
doubtless rank among the most frequent of urinary concre- 
tions. It is well known that patients ma} r void alkaline urine, 
turbid from undissolved earthy phosphates, for months without 
stone formation. 

Ammonio-M agnesium-Phosphate C oncretions. 
Calculi composed exclusively of this salt are uncommon ; 
but, on the other hand, it very frequentty forms the exterior of 
other forms of calculi, such as uric acid or calcium oxalate. 
Ammonio-magnesium-phosphate concretions are alwa} T s signifi- 
cant of ammoniacal urine, and herein lies the explanation of its 
frequency as a secondary deposit upon other primary concre- 
tions. The mechanical irritation set up by an}^ primary calculus 
of much size invariably leads to ammoniacal decomposition of 
the urine, usually in the bladder. The result of these changes 
is prompt precipitation of triple phosphates of highly -crystalline 
nature, and therefore readily tending to concrete upon any 
nucleus in the bladder. It has been stated that triple phosphate 
calculi are rare ; this applies to concretions of marked size. 

Mixed Phosphate Concretions. 

The most common variet}^ of mixed phosphatic calculi are 
those composed of calcium phosphate with triple phosphate of 
ammonium and magnesium. This has been termed the " fusible 
calculus," because under the blow-pipe it fuses into a black, 
enamel-like mass. These calculi often attain a large size. They 
are of grayish-white color, often covered on the surface with 
bright, glistening points, — triple phosphatic ciystals. In text- 
ure the} r are friable and somewhat spongy, often composed of 
concentric strata, easity fractured into thin laminae, the fract- 
ured surfaces often presenting bright deposits of crystalline 
triple phosphates. This calculus is very soluble in mineral 
acids, but is insoluble in water and alkalies ; its chief character- 
istic is its fusible property under the blow-pipe. 

These calculi nearl} T always form upon some other primary 






GRAVEL AND CALCULUS. 221 

nucleus, such as uric acid or calcium oxalate, and they often 
inerust fungous or other growths of the bladder. They are 
always the result of ammoniacal urine, and originate chiefly 
within the bladder. 

Calcium-Carbonate Concretions. 

Concretions of carbonate of lime belong to the rarer forms 
of calculi met with in human urine, very few authenticated cases 
being on record. They are small in size, of smooth surface, 
gray or bronze-like in color, and often very hard in texture. 
They are mostly spherical in shape, often translucent, and on 
section present numerous concentric lines. The nucleus is 
usually multiple, and upon crushing these calculi they break 
into sharp fragments. 

Other Forms of Concretions. 

A few additional varieties of concretions are occasionally 
met with in the urine. 

Fatty Concretions. — These consist of fatty matters saponified 
by the alkalies of the urine. This substance has received the 
name of urostealith, These concretions are soft and friable, 
usually of brownish or }^ellowish color, and often incrusted with 
phosphates. They burn with a flame when heated on platinum- 
foil, and give off an odor similar to resin or shellac. These 
calculi have only been met with a few times. 

Indigo Concretions. — Indigo has been met with in the urine 
in the form of calculus. It is doubtless derived from the in- 
doxyl-potassium sulphate of the urine, which ma}^ be changed 
by highly-acid urine into indigo. Such cases are exceedingly 
rare, however, but one or two having been recorded. 

Fibrin and blood concretions are mentioned as having been 
met with in the urine, but these must be looked upon as anoma- 
lous occurrences, except as forming the nucleus of other calcu- 
lous growths. 

Prostatic Concretions. — Prostatic calculi may be mentioned 
as sometimes encountered in the urine, although not strictly 
speaking urinary products. Sir Henry Thompson found these 
calculi invariably in the adult prostate at the autopsy. The} r 



222 ANALYSIS OF URINE. 

are found in the follicles of the prostate ; at first consisting 
entirely of albuminoid matter, they later become impregnated 
with earthy matter, and ultimately become as hard as other 
forms of calculi. It is exceptional that they give rise to special 
symptoms ; only so when they attain an unusual size and en- 
croach on the gland-tissue or project into the urethra. It is 
only exceptionally that these concretions are spontaneously dis- 
charged with the urine. 

Clinical Differentiation. — It would add greater precision to 
the treatment of calculus if the nature of the stone could be 
made out. The accuracy with which this can be compassed will 
vary considerably in different cases. The most trustworthy in- 
formation is obtainable from examination of calculi already 
voided with the urine. In a very considerable percentage of 
cases the habit of spontaneous expulsion of small concretions 
has been established. If the discovery of a retained calculus be 
not too remote from the spontaneous passage of a concretion 
which has been secured and examined, and, furthermore, if the 
characters of the urine correspond, it furnishes the most certain 
evidence of the nature of the retained calculus. It is of the 
utmost importance, therefore, to preserve all concretions that 
may be spontaneously Avoided with the urine, however minute 
they may be, and to make an accurate note of their composition, 
as well as of the characters of the urine at the time they were 
voided. 

In the absence of the above information it is still possible, 
in a large majority of cases, to make out with very great proba- 
bility the composition of the retained concretion. The evidences 
here are to be drawn from the characters of the urine — notably, 
its chemical reaction and the character of the deposits. In 
addition to these, certain inferences are to be drawn from the 
constitutional peculiarities of the patient, as well as the age, 
together with the known frequency of the different forms of 
concretions considered with regard to their location. 

If the urine be frankly acid at the time voided, the calculus is 
nearly certain to be either uric acid or calcium oxalate. Uric- 
acid calculi being by far the more frequent, the chances are in 
favor of the presence of that form of concretion. If, in addition 



GRAVEL AND CALCULUS. 223 

to the sharply-acid reaction of the urine, directly upon cooling 
it precipitates crystals of uric acid, and the symptoms appear in 
vigorous subjects addicted to the liberal use of meat diet, it 
becomes reasonably certain that the calculus is of the uric-acid 
form. 

If, on the other hand, the freshly-voided acid urine precipi- 
tate habitually the calcium-oxalate crystals, the patient being of 
sedentary habits and prone to indulgence in the use of both 
saccharine and proteid foods, it may be pretty confidently con- 
cluded that a calcium-oxalate calculus is retained. As already 
observed, calculi are very frequently met with composed of 
alternating layers of uric acid and calcium oxalate, because they 
are both the outgrowth of acid urine, as well as largely of simi- 
lar habits of living. But the predominance of either variety 
may usually be made out bjr repeated observation of the features 
just considered. C}^stin and xanthin concretions are also met 
with in acid urine, but these formations are so rare that they 
may, for practical purposes, be ignored, unless the presence of 
these substances be discovered in the urinary sediment, in which 
cases the probabilit} 7 of the presence of these rarer forms of 
calculi ma} r become a proper subject for consideration. 

The forms of calculi met with in alkaline urine next demand 
attention. For the most part these are vesical calculi. As a 
rule, the}' are more complex in composition, because the con- 
ditions of the urine during the formation and growth of these 
concretions are subject to greater change. Renal calculus is 
frequently composed of a single constituent, because its origin 
and growth is practically in the same location and subject to the 
same conditions of the urine throughout. With vesical calcu- 
lus, on the other hand, the nucleus may originate in the kidney 
when the urine is acid, or even alkaline from fixed alkali, while 
its subsequent development occurs in the bladder, where the 
urine ma}' be ammoniacal, as a consequence of its residence there 
or otherwise, and its growth will be influenced b} 7 the elements 
consequent to ammoniacal mine. 

The most frequent calculus met with in alkaline urine is that 
composed of mixed phosphates, or the calculus with uric-acid 
or urate nucleus covered with mixed phosphates. If the urine 



224 ANALYSIS OF URINE. 

be alkaline from fixed alkali, the calculus is pretty sure to con- 
sist of calcium carbonate or phosphate. In such cases the urine 
has usually long been alkaline, and the calculus is likely, accord- 
ingly, to consist uniformly of the same substance throughout. 

If the urine be ammoniacal the nucleus and body of the 
calculus is very likely to be composed of different substances. 
The nucleus may be uric acid, urates, or oxalate of lime, but 
the crust is pretty sure to consist of mixed phosphates. Re- 
membering the rapidity with which urine undergoes ammoniacal 
changes in vesical disturbances, special care should be ob- 
served to see if the urine be ammoniacal in these cases at the 
time it was voided, otherwise the observer may be greatly misled 
in his conclusions. The intensity of ammoniacal reaction of 
the urine, the deposit of phosphatic fragments, and the amount 
of deposit of triple-phosphate crystals, together with the grade 
of the accompanying cystitis, will furnish some idea of the age 
and magnitude of the phosphatic calculus. 

Analysis or Calculi. 
In conducting the analysis of urinary calculi the size, color, 
form, and density of the concretion should first be noted, as 
these often indicate, with considerable probability, their compo- 
sition, or at least the direction in which the chemical examination 
should be pursued. Since many calculi are composed of more 
than one deposit, in order to ascertain with greater precision the 
several components, section should first be made of the calculus 
by means of a fine saw. If the calculus be brittle it will often 
answer the purpose to break it into as large pieces as possible. 
Upon section or fracture, portions should be scraped from the 
different-appearing strata for separate examination. A portion 
of the calculus should first be subjected for some time to a red 
heat upon platinum-foil, either over a spirit-lamp or by means of 
a blow-pipe. In the latter case the best method is to lay the 
platinum-foil on a plaster-of-Paris cast, when the powdered cal- 
culus and foil may be raised to an}^ desired degree of heat with- 
out danger of burning the fingers. If upon ignition little or 
no fixed residue be left, the calculus is composed of some of 
the organic deposits — as uric acid, ammonium urate, xanthin, 



GRAVEL AND CALCULUS. 225 

cystin, proteid substances, or urostealith. If, on the other hand, 
the fused calculus leave a considerable residue, it consists of 
some of the inorganic bases, either alone or in combination, such 
as urates of sodium, potassium, or ammonium, calcium oxalate, 
calcium carbonate, calcium phosphate, or ammonio-magnesium 
phosphate. 

If the concretion burn up and leave little or no residue, it 
is necessary next to proceed by chemical methods to determine 
which of the organic deposits it be composed : — 

Uric Acid. — A portion of the powdered concretion is sub- 
mitted to the inurexid test (see page 33), and if the character- 
istic color-reaction be obtained with nitric acid and ammonia, 
the calculus consists of uric acid or ammonium urate. A por- 
tion of the finety-powdered calculus is subjected to boiling- 
water, when, if complete solution be effected, the calculus is am- 
monium urate ; but, if slightly or not at all solvent, it may be 
concluded that it is a uric-acid calculus. If further confirmation 
be necessaiy, let the solution stand until cool : ammonia will be 
evolved when treated with potassium hydroxid, if ammonium 
urate be present; and red litmus will be turned blue if suspended 
over the solution. If the result be negative — no ammonia 
present — the calculus is uric acid. 

Xanthin does not give murexid reaction, but its solution in 
nitric acid upon evaporation leaves a bright citron-yellow 
residue, insoluble in potassium carbonate, but soluble in potas- 
sium hydroxid, with resulting deep reddish-yellow color. 

Cystin does not give murexid reaction. Owing to its con- 
tained sulphur, if dissolved in potassium l^droxid and a little 
lead acetate be added, upon boiling a black precipitate of lead 
sulphide forms and imparts to the solution an \riky appearance. 
Cystin also dissolves in ammonia, and upon evaporation crys- 
tallizes in regular hexagonal plates. If dissolved in hydro- 
chloric acid and slowly evaporated, it forms diverging crystals 
arranged in sheaf-like form. 

Protein concretions do not give murexid reaction ; upon heat- 
ing they evolve the odor of burnt horn or feathers. They are 
insoluble in water, alcohol, and ether, but are soluble in potas- 
sium hydroxid. 

15 



226 ANALYSIS OF TJRINE. 

Urostealith gives no murexid reaction, but dissolves in ether, 
and }delds fatt3 T acids upon boiling with baryta-water. It dis- 
solves in potassium hydroxid when heated and becomes sapo- 
naceous. 

If the concretion be incombustible and leave, after ignition, 
a relatively large residue, it is necessaiy next to proceed to 
determine its composition, as follows: — 

Urates of the Fixed Alkalies (Sodium and Potassium Urates). 
— In order to isolate these fixed bases the concretion is finely 
powdered, and after boiling in distilled water is filtered. The 
urates pass through the filter in solution, while the less soluble 
uric acid remains on the filter. The solution is next evaporated 
and then ignited, and the residue consists of the fixed bases. If 
the residue turn moistened turmuric paper brown, it is either 
potassium or sodium; if it be the latter, it imparts to the flame 
of the blow-pipe a } T ellow color. 

Magnesium and calcium, if present in the residue, may be 
dissolved in dilute acids, and, upon addition of sodium phos- 
phate and ammonia, the calcium and magnesium are precipitated 
as ammonio-magnesium and lime phosphates. 

Calcium Oxalate. — These concretions first blacken upon 
heating, but upon further ignition they finally leave considerable 
white ash, which dissolves in hydrochloric acid with effervescence. 
If this solution be neutralized with ammonia, and oxalic acid 
be added, characteristic envelope-shaped crystals of calcium 
oxalate are precipitated, and may be recognized readily by the 
microscope. 

Calcium carbonate, like calcium oxalate, at first blackens 
upon ignition, but ultimately burns white, leaving considerable 
infusible ash. Calcium carbonate, however, is distinguished 
from calcic oxalate by its highty-characteristic property of dis- 
solving in li3 T drochloric acid with effervescence. It will be 
remembered that the fused ash of calcium oxalate — not the cal- 
culus — dissolves in hydrochloric acid with effervescence. 

Ammonio-magnesium phosphate with more or less calcium 
phosphate usuall}^ occur together, and as such constitute the 
mixed phosphatic or fusible calculus. Upon ignition this cal- 
culus melts into an enamel-like mass. Upon prolonged ignition 



GRAVEL AND CALCULUS. 



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228 ANALYSIS OF URINE. 

they do not show an alkaline reaction like calcium oxalate and 
carbonate. The fused ash of this calculus dissolves in hydro- 
chloric acid without effervescence. 

The excellent table on preceding page, from Heller, shows at 
a glance the chief features of the analysis of the various calculi, 
and will be found to greatly facilitate the analysis of calculus by 
the student. 



Part II. 

Urinary Diagnosis. 



DISEASES OF THE URINARY ORGANS AND URINARY 
DISORDERS. 

THE URINE IN OTHER DISEASES. 



(229) 



SECTION IX. 

DISEASES OF THE URINARY ORGANS, AND URINARY 
DISORDERS. 

Urinary diagnosis, as considered in the subsequent pages of 
this work, will include : First, diagnostic data derivable from the 
urine which relate directly to pathological conditions of the 
urinary organs themselves. Second, diagnostic data derivable 
from the urine which relate to pathological conditions, either 
local or general, but the prominent feature of which is some 
marked and characteristic departure from the normal condition 
of the urine itself. Third, diagnostic data derivable from the 
urine which relate to pathological conditions primarily inde- 
pendent of the urinary organs, in which the latter may or may 
not become involved. 

In order to bring the range of urinary diagnosis more fully 
within the field of practical clinical work, the plan will be fol- 
lowed of first describing the changes effected in the urine by the 
various forms of disease, followed by a brief epitome of the 
leading clinical symptoms, and, where necessary, also the differ- 
ential features in each case. 

A perusal of the eight preceding sections will familiarize the 
student with the process of secretion and excretion of the urine ; 
the chemical and microscopical characters of the latter, both 
normal and abnormal ; and the clinical significance of the various 
morbid products met with in the urine in the course of disease. 
In order now to compass the entire groundwork of knowledge 
essential for practical urinary diagnosis, it only remains to con- 
sider the most approved methods of physical examination of the 
urinary organs themselves. This requires a practical knowl- 
edge of the regional anatomy of the urinary organs, and, while 
doubtless most readers of this volume are already familiar with 
the subject through the numerous and excellent text-books on 
anatomy now in general use, it is j T et believed that a brief and 
practical survey of the subject here will facilitate the study of 
the subjects shortly to be considered. 

(231) 



232 urinary diagnosis. 

Anatomical Considerations. 

The Kidneys. — These are two large, glandular organs situated 
in the upper and posterior part of the abdominal cavity, on 
either side of the spinal column. Each kidney is about four 
inches in length, two inches in its transverse diameter, and 
rather more than one inch in thickness. These dimensions vary 
somewhat in individual cases. The left kidney is ordinarily 
slightly longer and narrower than the right kidney. The weight 
of each kidney is from 4 to 5 ounces, the male kidney being 
ordinarily 2 or 3 drachms heavier than that of the female. The 
left kidney in both sexes weighs about 100 grains more than the 
right one. The combined weight of both organs, in proportion 
to the body-weight, is about 1 to 240. 

In form the kidney resembles a "haricot," or u kidney -bean." 
It is compressed from either side, presenting an anterior and 
posterior surface, both of which are slightly convex, the anterior 
surface most so. The outer border presents an elongated con- 
vex line, while the inner border is concave, with a deep notch in 
the centre, — " the hilum." The upper and lower extremities of 
the kidney are slightly wider than the middle of the organ, the 
upper being somewhat the wider of the two. The anterior sur- 
faces of the kidneys look obliquely outward and forward from 
either side of the bodies of the vertebrae. The posterior surfaces 
of the kidneys — rather more flattened than the anterior — look 
obliquely backward and inward toward the spines of the verte- 
brae. The upper end of the kidney — somewhat knobbed and 
larger than the lower — is nearer the spinal column, and has a 
slightly more posterior position than the lower end. The inner 
border of the kidney, at its upper part, is about one inch from 
the middle line of the bod}^ ; the outer border, at its lower part, 
is three and three-fourths inches from the middle line of the 
body. The outer or convex border of the kidney looks obliquely 
upward, while the concave or inner border looks obliquely 
downward and forward. 

The kidneys are situated deep in the loins, on either side of 
the vertebral column. The upper border of the kidney corre- 
sponds with the space between the eleventh and twelfth ribs, 
while the lower border corresponds with the middle of the third 



ANATOMICAL CONSIDERATIONS 



233 



lumbar vertebra. The pelvis of the kidney is about on a level 
with the spine of the first lumbar vertebra. During deep inspi- 
ration both kidneys are usually depressed by the diaphragm 
about half an inch, though not always so. 

" An horizontal line passing through the umbilicus would lie 
just below the lower borders of both kidneys ; while a vertical line 




Fig. 36.— -Topographical Relations of Kidneys, Anteriorly. 
(After Morris.) 



extending perpendicularly upward from the middle of Poupart's 
ligament to the costal arch would pass directly over the kidney, 
slightly external to its median line. Posteriorly, a line parallel 
with and one inch from the vertebral column, extending from 
the lower edge of the tip of the spinous process of the eleventh 
dorsal vertebra to the lower edge of the spinous process of the 
third lumbar vertebra, would fall just inside of the inner border 



234 



URINARY DIAGNOSIS. 



of the kidney. If now two lines be drawn, from the ends of the 
line just described, horizontally outward for two and three-fourths 
inches, and if the outer ends of these two lines be joined by a 
perpendicular line, the whole kidney would normally lie within 
the four lines described '* (Morris). 

The kidneys rest on the crura of the diaphragm, on the 
anterior lamella of the posterior aponeurosis of the transversalis 




Fig. 37.— Topographical Relations of Kidneys. Posteriorly. 
(After Morris.) 

muscle. To a slight extent they also rest upon the psoas muscle. 
The right kidney is somewhat lower than the left, owing to the 
position of the liver, which it touches by its suprarenal capsule 
at its upper end ; then the peritoneum passes over its anterior 
surface near the upper end. and the duodenum and commence- 
ment of the transverse colon are in contact with it where they 
are uncovered by peritoneum. The left kidney, rather higher 



ANATOMICAL CONSIDERATIONS. 



235 



than the right, is covered in front 03^ the great end of the 
stomach, the spleen, and the descending colon. The front of the 
organ touches the fundus of the stomach, and then comes in 
contact with the pancreas and, lower down, with the commence- 
ment of the descending colon. The external border of the left 
kidney, in the upper two-thirds of its extent, is in contact with the 
spleen. (See Fig. 38.) 

The kidneys are surrounded by a thick layer of fat contained 




Fig. 38.— Relations of the Kidneys. (After Sappey.) 

1-1, the two kidneys; 2-2, fibrous capsules; 3, pelvis of the kidney; 4, ureter; 5, 
renal artery ; 6, renal vein ; 7, suprarenal body ; 8-8, liver, raised to show relations of its 
lower surface to right kidney; 9, gall-bladder ; 10, terminus of portal vein ; 11, origin of 
common bile-duct; 12. spleen, turned outward to show relations with left kidney; 13, semi- 
circular pouch on which the lower end of the spleen rests; 14, abdominal aorta; 15, vena 
cava inferior ; 16, left spermatic vein and artery: 17. right spermatic vein, opening into 
vena cava inferior ; 18, subperitoneal fibrous layer or fascia propria, dividing to form renal 
sheaths ; 19, lower end of quadratus lumborum muscle. 

in the meshes of a loose areolar tissue and constitute the " tunica 
adiposa." It is thicker and more abundant posteriorly than 
anteriorly, but everywhere it completely invests the fibrous cap- 
sule of the organs. The amount of fat contained in the tunica 
adiposa is subject to great variation in different subjects. This 



236 URINARY DIAGNOSIS. 

fact should not be forgotten, since in stout persons it may be so 
pronounced as to mislead one as to the size of the kidney itself. 
On the other hand, in spare subjects, the fatty elements of the 
tunica adiposa may become so far absorbed that this tunic 
becomes loose, and its connections with the kidney and sur- 
rounding parts are relaxed so that the kidneys are capable of a 
very considerable degree of mobility. 

The capsule of the kidney is a thin, smooth, firm, and closely- 
fitting envelope. Composed of numerous firm, elastic fibres, it 
possesses considerable power of stretching and contracting, 
regulated by the degree of vascular tension of the kidney. The 
capsule adheres, by minute fibres of connective tissue and capil- 
lary vessels, to the surface of the kidney, from which, however, 
it can be readily separated in the healthy organ without dragging 
any of the glandular structure of the organ proper with it. The 
capsule, following the notch or hilum in the renal substance, 
passes into the sinus of the kidney and becomes continuous, 
around the bases of the papillae of the pyramids, with the 
stronger external fibres and elastic tissues of the calyces and 
pelvis. The pedicle of the kidney is composed of the dilated 
upper end of the ureter, the renal artery and vein, a quantity 
of connective tissue, and a large number of lymphatics and 
nerves. The relations of the vessels and ureter to each other in 
the pedicle are as follow : From above downward, artery, vein, 
and ureter; from before backward, vein, artery, and ureter. 
This arrangement occasionally varies. 

The kidney is liberally supplied with blood ; indeed, out of 
all proportion so, according to its relative size. The renal artery 
is of large size and arises from the aorta a little below the origin 
of the superior mesenteric arteiy, the right usually arising a 
little lower than the left. As the aorta lies to the left of the 
median line, the right renal artery is longer than the left and 
crosses behind the vena cava inferior. Before reaching the 
notch or hilum of the kidney each artery divides into four or 
five chief branches, which sink into the sinus behind the corre- 
sponding branches of the renal vein and in front of the pelvis. 
Deep in the notch of the kidney these branches break up into 
a number of smaller branches, which leave the veins between 



ANATOMICAL CONSIDERATIONS. 23 f 

the calyces and enter the substance of the kidney between the 
papillae. 

The renal vein is a short, wide vessel, and, like the artery, 
takes an almost horizontal course. Its primary branches — four 
or five in number — issue from the hilum in front of the arterial 
branches, and then the vein continues in front of the artery until 
it joins the vena cava. The left renal vein is joined by the sper- 
matic vein, both right and left renal veins receiving branches 
from the suprarenal capsule of their respective sides. 

The nerves of the kidney consist of filaments from both the 
sympathetic and cerebro-spinal systems. They accompany the 
renal artery, and are derived from the renal plexus and the lesser 
splanchnic nerve. 

The kidneys are surmounted by two small, yellowish, flat- 
tened bodies, — the suprarenal capsules, — which dip slightly 
downward over the upper borders. The right one is somewhat 
triangular-shaped, the left one semilunar. They are connected 
with the kidneys by the common investing areolar tissue, and 
each capsule is marked on its anterior surface by a fissure which 
appears to divide it into two lobes. The right suprarenal body 
is closely adherent to the posterior and under surface of the 
liver ; the left lies in contact with the pancreas and spleen. Both 
capsules rest against the crura of the diaphragm, on a level with 
the tenth dorsal vertebra, and by their inner borders are in rela- 
tion with the great splanchnic nerve and semilunar ganglion. 

The Renal Pelvis. — As the ureter passes upward it loses its 
cylindrical form on a level with the lower end of thelridney, and 
it there begins to expand into a large, funnel-shaped dilatation, 
which is known as the " pelvis " of the kidney. After entering 
the hilum or notch the pelvis divides into two or three primary 
tubular branches, which in turn end in several short truncated 
but wide pouches, named calyces or infundibula, the mouths of 
which receive the papillae as " does a glove the fingers." A 
single calyx often surrounds two or three papillae, so that the 
calyces are fewer in number than the pyramids of the kidney. 

The Ureter begins at the lower, pointed end of the funnel- 
shaped renal pelvis, at a point about the level of the lower 
border of the kidney, and extends, in length from fourteen to 



238 URINARY DIAGNOSIS. 

sixteen inches, to the base of the bladder, into which it opens by 
a constricted, slit-like opening, after having passed obliquely for 
nearly an inch between its muscular and mucous coats. 

The ureter is a cylindrical, membranous tube, about the 
diameter of a goose-quill; but the lumen of the tube is not 
uniform. The ureter, in passing downward and inward to the 
brim of the pelvis, lies directly behind the peritoneum, resting on 
the psoas muscle, and is crossed by the spermatic vessels. In 
the pelvis it enters the peritoneal fold constituting the posterior 
false ligament of the bladder, and runs downward and forward 
by the side of the bladder, entering the wall of the latter about 
two inches from the ureter of the opposite side. In the female 
the ureters pass by the neck of the uterus, about an inch from 
the latter. 

The Bladder. — This is a hollow, musculo-membranous organ 
situated behind the pubis within the pelvis, in front of the rectum 
in the male, the uterus and vagina intervening between it and 
the rectum in the female. The shape of the bladder varies with 
the age, sex, and degree of distension of the organ. In infanc}' 
it is conical in form and projects above the pubis. In the adult, 
when empty, it is small and triangular in form, situated deeply 
in the pelvis, flattened from before backward, and rises on a 
level with the upper border of the pubic sympli3'sis. When 
slightly distended, the bladder is rounded in form and partly 
fills the pelvis ; when greatly distended it is oval in shape and 
rises into the abdominal cavitj\ sometimes extending as far as 
the umbilicus. It is largest in its vertical diameter, and its long- 
axis is directed obliquely downward and backward. When mod- 
erately distended (containing one pint) it measures about five 
inches in length by about three inches in width. The bladder is 
divided into summit, body, base, and neck. The summit consti- 
tutes the upper, rounded border of the organ, which is covered 
by peritoneum. The bod}' of the bladder, posterior^, is also 
covered by peritoneum, but anteriorly it is uncovered by that 
membrane. The base of the bladder is directed downward and 
backward, resting, in the male, upon the rectum ; in the female, 
lying in contact with the lower part of the cervix uteri, and ad- 
herent to the anterior vaginal wall. The neck of the bladder is 



PHYSICAL EXAMINATION. 239 

the constricted portion continuous with the urethra; in the mule, 
surrounded by the prostate gland. 

Physical Examination. 

For examination of the kidney by means of percussion the 
patient should lie upon the abdomen, across a rather hard 
pillow. In this position there will be found, in the lumbar 
region of the normal subject with normal kidneys, a space 
between the last rib and the pelvic brim, rather less than 
two inches broad, — five centimetres, — which elicits a dull note 
upon sharp percussion. Anteriorly, this dullness is abruptly 
exchanged for tympanitic resonance as the intestines are ap- 
proached. The dull note is continuous upward and outward 
beyond the limits of the kidney : on the right side continuous 
with that due to the liver ; on the left side continuous with that 
due to the spleen ; while below, the pelvic brim (within which 
the lower border of the kidney lies) prevents the lower border 
of the kidney from being defined. It will, therefore, be seen 
that the normal kidney elicits but little information upon per- 
cussion, owing to its unfavorable position for that purpose, for 
even moderately-enlarged kidneys cannot, with percussion, be 
thus outlined. " Obscured by the thickness of the abdominal 
walls, covered in part by the lower ribs, liver, and spleen, in 
part arched over by the vertebral processes, covered by the 
body of the sacro-spinatus muscle, the lateral border of which 
closely corresponds with the convex border of the kidney, it 
will be readily seen that these organs present the greatest obsta- 
cles to percussion." In abnormal conditions of the kidney, how- 
ever, notably those of large tumor, percussion becomes of very 
decided utility, but for such purposes the patient should be 
placed upon the back, in the position for palpation. 

Palpation of the kidney is best conducted by placing the 
patient upon the back, with the thighs slightly flexed and some- 
what separated from each other. The examiner should approach 
the side of the patient which he desires to palpate, and with one 
hand upon the anterior wall of the abdomen he should pass the 
other hand behind the patient, pressing deeply with his fingers 
from behind forward in the renal region (between the lower 



240 URINARY DIAGNOSIS. 

border of the ribs and the iliac crest), pushing firmly forward 
any tumor against the opposite hand. 

In pathological conditions of the kidneys, notabty if the 
organs be very much enlarged or displaced, phj'sical examination 
often elicits valuable diagnostic information. Thus, in the case 
of morbid growths, some knowledge of their nature is obtain- 
able by the sense of touch and manipulation. Thus, the organs 
may feel smooth, uneven, globular, lobulated, fluctuant, soft, or 
dense. They move but slightly with respiration. If tumor be 
present, the kidney ma}^ leave its normal bed beneath the dia- 
phragm and be seen in front ; but a normal movable kidney is 
not visible upon anterior inspection. 

A circular, symmetrical swelling between the borders of the 
ribs and the pelvic brim, extending posteriorly toward the spine, 
with cedematous condition of the skin and tissues beneath, may 
point to perinephritis with perinephritic abscess. Tenderness 
upon pressure is obtainable in acute, but rarely, if ever, in 
chronic, diffuse nephritis. It is present in renal stone, espe- 
cially if the latter has excited inflammation. In Irydronephrosis 
it is usually present, and in perinephritis it is especially promi- 
nent. Large formations, as carcinoma, sarcoma, hydronephro- 
sis, pyonephrosis, perinephritis, and echinococcus, are plainly 
palpable ; the latter may show, by quick, short, bimanual 
percussion-strokes, a peculiar whiz, — the " hydatid vibration." 
Since the kidney lies behind the peritoneum, when it becomes 
enlarged by growths so as to extend forward it usually pushes 
before it the ascending or descending colon against the anterior 
abdominal wall ; in such case the colon may be made to fur- 
nish valuable differential knowledge, because other abdominal 
growths, being intra-peritoneal, push the colon aside, and there- 
fore furnish no tympanitic note from this source. Since the 
colon is best distinguished when it contains air, it is often 
advisable to inflate it for diagnostic purposes. Movable kidney 
is known by its form, mobility, size, often its capability of 
replacement, and occasionally pulsation of the renal artery may 
be felt. 

Although palpation is usually sufficient to reveal the pres- 
ence of renal tumors of any considerable size, anterior or 



PHYSICAL EXAMINATION. 241 

lateral percussion is usefully employed for confirmative purposes. 
Iu the author's experience, one of the most valuable methods is 
that of anterior auscultatory percussion for this special purpose. 
By placing the stethoscope over the centre of a viscus or tumor, 
and by the finger-tips very gently tapping the abdominal wall in 
a radiating direction from the instrument, the outline of the 
body upon which the stethoscope rests can be made out with 
great precision by the impulse and pitch of the note conveyed 
to the ear. 

The method of diagnosticating unilateral dislocation of the 
kidney by bilateral percussion, upon the theory of differential 
bilateral resonance, although formerty much relied upon, has, 
upon wider experience, proved untrustworthy. 

The differential features between renal tumors and those of 
adjacent organs often require most careful consideration. Thus, 
the differential features between a moderately displaced right 
kidney downward and a distended gall-bladder, an echinococcus 
cyst or other growth upon the lower border of the liver is not 
readily made out by palpation or percussion. Respiratory mo- 
bility, if pronounced, may, with considerable degree of certainty, 
exclude the kidney. Capability of replacement, on the other 
hand, so that the tumor disappears, proves the tumor to be renal. 
Movable left kidney is differentiated from movable spleen by 
palpation and percussion. Palpation may reveal characteristic 
notches in case of the spleen ; while in movable kidney the 
pulsations of the renal artery may sometimes be felt by deep 
pressure at the hilum of the organ. The course and relations 
of the colon, as ascertained by percussion, are also here valuable 
guides. Respirator}^ mobility may or may not accompan j' splenic 
enlargement ; if present it argues against the renal nature of the 
tumor. 

The ureters are so inaccessible that they furnish but little 
information upon palpation or percussion. A few surgeons, 
notably Simon, have repeatedly felt the ureters by anaesthetizing 
the patient and introducing the hand into the rectum. Recently 
palpation of the ureters per vaginam has come to be practiced. 
This offers no special difficulty, as the ureters can be plainly felt 
for nearly three inches of their lower extremities, and growths 



242 URINARY DIAGNOSIS. 

or stones in this portion of the canal can be clearly made out. 
To a less extent palpation of the ureter may be practiced per 
rectum with the finger, but onl} r about the last inch or so of the 
tube can thus be ordinarily defined, as it lies within the bladder- 
wall. 

Abdominal palpation is rarely successful in ureteral exami- 
nations, and only in cases of very spare subjects, when the ureters 
are greatly distended or are occupied by large growths. The 
vesical orifice of the ureter may be inspected by means of the 
cystoscope, and morbid conditions of that part of the canal can 
be determined satisfactorily. Catheterization of the ureters, as 
yet, is applicable only to limited cases — in the female. This 
immensely valuable means of diagnosis, especially desirable for 
renal as well as ureteral purposes, must very shortly be per- 
fected in connection with the cj^stoscope. The author's instru- 
ment, devised by Leiter for this purpose, has never proved satis- 
factory ; nor can an}*- of the instruments in present use be 
depended upon to meet the purpose. 

The bladder is only noticeable on external inspection in cases 
of extreme distension, when it rises into the abdominal cavity. 
Palpation is applicable in moderate distension of the bladder 
above the symphysis pubis. It may also be practiced per 
vaginam and per rectum either by one hand or, often with ad- 
vantage, bimanually. Sir Henry Thompson proposed and prac- 
ticed digital exploration of the bladder by opening the urethra 
at or about the membranous portion and making a passage 
sufficient to admit the index finger into the bladder. While 
the operation is in itself usually a harmless one, more recent 
measures (the cystoscope) for the most part render it unneces- 
sary. Percussion over the region of the bladder reveals an area 
of more or less extended dullness, according to the degree of 
distension of the organ. But percussion of the bladder for 
the purpose of distinguishing tumors of the vesical region is 
scarcely necessary, since catheterization will usually quickly 
determine if they be of vesical origin or not. 

A very decided advance in our methods of inspecting the 
bladder has taken place since 1887, when Nitze first published 
his methods of examination of the bladder 03^ means of electric 



ACUTE RENAL HYPEREMIA. 243 

illumination. 1 Since then the complete work of Fenwick on 
"Electric Illumination of the Bladder and Urethra " (1888) and 
Nitze's "Text-Book of Cystoscopy " (1889) have furnished in 
detail all the technique of this method of examination of the 
bladder. By means of the cystoscope we are now able to obtain 
most complete knowledge of a large number of pathological 
conditions of the bladder. " Its use plainly discloses ulcera- 
tions, their character and extent. It enables us to see diver- 
ticula, to find and locate foreign bodies, to not only plainly see 
stones, but also to ascertain their size, number, shape, character, 
and even to percuss them with the instrument, the encysted 
stones no longer escaping detection. Above all, the diagnosis 
of morbid growths of the bladder b}< this means is rendered 
comparatively easy and sufficiently early to render far more 
efficient their treatment." Certainly, no longer can a diagnosis 
of obscure disease of the bladder be considered complete without 
the use of the cystoscope. 

Renal Hyperemia. 
Hyperemia of the kidneys is met with in two forms : (a) 
active or acute hyperemia, consisting of active determination of 
arterial blood to the kidneys ; (6) passive hyperemia, or venous 
stasis, consisting of a retention of venous blood in the kidneys, 
usually the result of some obstruction to the venous circulation, 
either local or general. 

ACUTE RENAL HYPEREMIA. 

This condition may be said to mark the initial stage of nearly 
all forms of acute nephritis. It may be brought about by 
numerous causes. In the course of eruptive fevers and inflam- 
matory diseases, such as diphtheria, erysipelas, pneumonia, and 
acute rheumatism, the kidneys, in common with other internal 
organs, become more or less pronouncedly hyperemic. Toxic 
influences and certain irritants are very common causes of renal 
hyperemia. If the toxin or irritant be quickly removed, the 
normal condition of the renal circulation is rapidly established 

1 " Contribution to Endoscopy of the Male Bladder," Archiv f. klin. 
Chir., vol. xxxvi, p. 661. 



244 URINARY DIAGNOSIS. 

again ; but if protracted sufficiently long, the prolonged hyper- 
emia is very apt to result in active nephritis. 

A number of substances when swallowed are capable of 
inducing active renal l^persemia, the best known of which are 
cantharidis, turpentine, sulphuric and other mineral acids, phos- 
phorus, cubebs, and potassium chlorate. Acute renal hyper- 
emia may also be induced b}^ local auto-irritation, as in the case 
of lithuria and oxaluria when long continued. Exposure to 
cold and moisture constitutes a frequent cause of the condition 
under consideration. In the majority of such cases the hyper- 
emia subsides without, perhaps, having attracted special atten- 
tion, but sometimes it passes on into acute nephritis. In late 
stages of diabetes the kidneys usually become hyperemic, and 
even albuminuria and mild grades of nephritis may also result. 

The Urine. — In acute hyperemia of the kidneys the urine 
contains more or less blood, the quantity depending upon the 
degree of congestion present. In mild cases only a few scatter- 
ing corpuscles are to be seen, while in active congestion the 
urine may be very bloody. The color of the urine will depend 
mostly upon the degree of hemorrhage. Albumin is always 
present, but usually in small amount, rarely exceeding 10 or 15 
per cent, bulk measure. The urine usually contains a few renal 
casts, mostly of the h} T aline order, and of small size ; and free epi- 
thelium from the renal tubules may often, though not invariant, 
be observed. The quantity of urine at first is increased, and, 
corresponding to this, the specific gravity is somewhat reduced, 
and the proportion of solids is reduced, though the absolute 
solids may be normal. The urine retains its normal acidity. 

If the congestion continue long, most of the physical char- 
acters of the urine just named are apt to become reversed. The 
specific gravity becomes increased, as do the solids, w T hile the 
quantity becomes diminished. In some cases of acute renal 
hyperemia, especially when induced by cantharidis, fibrinous 
coagula may appear in the urine. 

Leading Clinical Features. — When the cause is toxic, the 
symptoms are to be looked for in the resultant effects on other 
organs of the substance ingested. Locally, more or less fre- 
quency of micturition is present, sometimes with pain, urgency, 



PASSIVE RENAL HYPEREMIA. 245 

and perhaps vesical tenesmus. Some pain is apt to be present 
in the region of the kidneys, but, in the absence of this, some 
tenderness may usually be elicited upon deep pressure in the 
same location. In febrile forms the usual features of pyrexia 
are to be observed, more or less marked, according to the grade 
and character of the fever present. 

PASSIVE RENAL HYPEREMIA. 

Venous stasis or passive hyperemia of the kidneys is not at 
any time a primary renal disease, but is always secondary to 




Fig. 39.— Urinary Sediment in Passive Hypkiuemia of the Kidneys. 
(After Peyer.) 

some obstructive disease of the heart or circulatory organs. 
Mitral disease of the heart and valvular insufficienc}^, or stenosis, 
are the active causes of most of these cases. 

The Urine. — The quantity of the urine in uncomplicated cases 
is always diminished, and the specific gravity is increased, usu- 
ally ranging from 1025 to 1030. The color of the urine is dark 
brownish-red, and the chemical reaction is frankly acid. The 



246 URINARY DIAGNOSIS. 

transparency of the urine is somewhat diminished, owing to the 
presence of undissolved urates and increase of mucus. The 
quantity of uric acid is relatively, and sometimes absolutely, 
increased, and free uric-acid ciystals are usually to be seen in 
the sediment, as are the amorphous urates. There is usually 
no reduction, either in the relative or absolute quantity of 
urea present. The urine usually contains a small and variable 
amount of albumin ; sometimes merely traces are present ; occa- 
sionally, though rarely, it is absent, while sometimes it may 
reach one or two grammes per litre ; the degree of stasis, seem- 
ingly, does not correspond with the degree of albuminuria. The 
sediment usually contains a few hyaline casts of small size, and, 
occasionally, scattering blood-discs or nuclei may be seen at- 
tached to these casts (Fig. 39). A few scattering blood-cor- 
puscles are usually to be seen in the sediment ; occasionally this 
is considerable, although such is more rarely the case than the 
appearance of the urine would indicate, owing to the concentra- 
tion of the urine. 

Leading Clinical Symptoms. — These are very characteristic, 
and comprise dropsy, mostly of the feet and lower extremities ; 
general C} r anosis, d} T spncea, hacking cough ; prominence of the 
large veins, notably those of the abdomen ; weak, thread}^ pulse, 
and cardiac lesions. 

Differentiation. — Venous stasis of the kidne3 T is to be dis- 
tinguished from interstitial nephritis b}^ the increased volume 
of the urine in the latter disease, its low specific gravity, pale 
color, normal transparency, spare deposit ; absence, as a rule, of 
blood from the deposit, and constant deficiency of urea, both 
relatively and absolutely. To these may be added, as the most 
prominent clinical features of interstitial nephritis, a full, hard 
pulse, always showing increased tension; cardiac enlargement 
(left ventricle hypertrophied), visual disorders in late stages, 
absence of drops} T till very late, chronic ursemic disturbances, 
and the habit of nocturnal micturition, — all of which are absent 
in passive renal hypersemia. 



acute diffuse nephritis. 247 

Acute Diffuse Nephritis. 

This is the so-called acute Bright's disease, and is marked by 
very pronounced and characteristic features, clinically as well as 
urinary. The causes include those already considered as provo- 
cative of acute renal hyperemia, any of which, if of sufficient 
intensity or duration, are capable of bringing on acute diffuse 
nephritis. Of the use of toxic drugs, as a matter of actual experi- 
ence, acute nephritis is rarely thus induced, probably because 
the exciting cause is rarely prolonged sufficiently to bring about 
high grades of nephritis. Acute diffuse nephritis is most often 
met with in practice as a result of the acute infectious fevers, 
notably scarlatina, pneumonia, typhoid fever, diphtheria, relaps- 
ing fever, and epidemic influenza. Less often violent exposure to 
cold and certain local affections of the skin, including extensive 
burns, erysipelas, carbuncles, etc., give rise to this disease. 
Lastly, pregnancy must be recognized as the causative factor of 
a very considerable number of these cases. 

The Urine. — In acute diffuse nephritis the urine possesses 
the following typical characteristics : The quantity is invariably 
diminished, and sometimes extremely so. At the height of the 
disease but a few ounces of urine may be voided during the 
whole twent3 T -four hours ; but later on, if improvement occur, 
the quantity gradually increases until the normal volume, or 
even more, may be reached. If the quantity of urine rise above 
the normal it may be taken as an evidence that the acute char- 
acter of the disease is modified, and the tendency is toward reso- 
lution. On the other hand the urine, at the very height of acute 
nephritis, ma}^ become practically suppressed, and, if this con- 
tinue, death may be invariably predicted within a very few days. 

The specific gravity of the urine depends upon the quantity 
voided, and, as already shown, this varies with the course of the 
disease; so will this feature of the urine. In the early and very 
acute stage of the disease the specific gravity of the urine usu- 
ally rises above normal, often reaching 1025 to 1030 or even 
higher. With continuance of the disease the tendency is toward 
a lowered specific gravity of the urine, corresponding with the 
increased volume. 

The color of the urine varies considerably at different periods 



248 URINARY DIAGNOSIS. 

of the disease, the variation depending in part upon the quantity 
of urine voided, and in part upon the quantity of contained 
blood. As a rule, the color of the urine is dark, more or less 
approaching chocolate color. The transparency of the urine is 
diminished, the urine presenting a smoky, opaque appearance, 
in which the normal lustre is completely lost. A diminution of 
this character of the urine denotes changes tending toward reso- 
lution. The chemical reaction of the urine, uninfluenced by 
medication, is always sharply acid; but upon the use of alkaline 
salts, so much employed in treatment, the urine is often found 
to be alkaline. 

The gross quantity of the urinary solids is diminished in 
acute nephritis, the urea suffering the most pronounced reduc- 
tion. The relative amount of solids varies with the volume of 
urine excreted ; so that in the early stage, marked by great re- 
duction in the volume of urine, the relative amount of solids 
may be normal or above. It is important to make the distinction 
here, however, that the gross solids for twent3 r -four hours are 
always reduced. Upon convalescence the gross solids are in- 
creased, especially the urea and chlorides, which were merely 
held back. At the height of the disease the urea is often re- 
duced to 100 grains or even less for twenty-four hours. The 
urine contains albumin in variable, but always large amount in 
acute nephritis. It may reach as high as 2 per cent., or even 
more by actual weight ; so that upon coagulation it nearly fills 
the test-tube. More frequently, however, the range is in the 
vicinit}^ of \ to 1 per cent., — 5 to 10 grammes per litre (Esbach's 
method). A few cases of acute nephritis following scarlatina 
are recorded, in which the urine was free from albumin. It is, 
however, rare in such cases that albuminuria is absent through- 
out the whole course of the disease ; more often it is of sudden 
onset at some stage, and occasional^ it has been observed in 
intermittent form. 

The degree of albuminuria is considered to mark the degree 
and course of acute nephritis toward a favorable or unfavorable 
termination ; and while the degree of albuminuria can rarely be 
taken as a safe guide in this direction in general, it may be more 
depended upon as such in this special form of nephritis than 



ACUTE DIFFUSE NEPHRITIS. 249 

perhaps in an}^ other form of renal disease. On the whole, a 
continuous diminution in the quantity of albumin in the urine 
in acute nephritis may be accepted as evidence of progress 
toward resolution. 

The presence of blood in the urine may be regarded as one 
of the essential features of this disease, though varying greatly 
in amount in different cases as well as at different periods in 
the same case. Fluctuations are frequent during the course of 
the disease, and, indeed, the blood may alternately appear and 
disappear. Hematuria is developed early, being in most cases 
among the first symptoms noticed, while it usually subsides 
much earlier than does albuminuria. The quantity of blood 
lost in the average case of acute nephritis is very considerable 
if the disease continue long; this is partly evident b}^ the in- 
creasing pallor of these subjects. Hematuria may be regarded 
as a valuable prognostic indication in this disease, being rarely 
absent in severe cases ; its appearance marks, with early and great 
certaint3 r , relapses of the acute process, when previous progress 
was favorable. 

The urinary sediment in acute diffuse nephritis is large in 
quantity, usualty brownish in color from admixture with blood, 
urates, and coloring matters. Microscopical investigation of the 
sediment discloses the presence of red blood-corpuscles in larger 
or smaller numbers. These are somewhat altered, and appear 
" ivashed out" and ragged, unless in cases of marked haemor- 
rhage, when they present more nearly their normal appearance. 
Some pus-corpuscles are to be noted in the field, but rarely in 
any considerable number. Cellular forms are characteristic of 
this deposit; mostty small, round, uninuclear cells from the renal 
tubules, which may be present in great numbers; while less 
numerous are the narrow-pointed, small-tailed cells from the 
renal pelvis. The epithelium is well preserved, and affords char- 
acteristic pictures of these structures under the microscope. 
Renal casts are present in large numbers, and may have attached 
to them (a) blood-corpuscles, (b) leucocytes, (c) renal epithelium 
(Fig. 40). The above varieties of casts are characteristic of the 
beginning of acute nephritis, or the disease at its height; but 
they are subject to alterations in character as the disease con- 



250 



URINARY DIAGNOSIS. 



tinues some time. With advancing changes consequent to 
the disease, disorganization of the epithelium occurs, and we 
find the metamorphosed casts, such as the dark, granular, 
and broad, lryaline ones, with more or less organic molecular 
debris. With advance toward resolution the quantity of sedi- 
ment diminishes and the casts become less and less numerous. 
As already noted, the uric acid of the urine is increased in acute 
nephritis, the chlorides are diminished, and in very acute cases 




Fig. 40.— Urinary Sediment in Acute Nephritis. (After Peyer.) 



the latter maj 7 disappear altogether. When advancing toward 
recovery the volume of urine increases, and with this diuresis 
the chlorides and urea become markedly increased, having been 
held back by defective eliminative power of the kidney during 
the height of the disease. 

Leading Clinical Features. — The most prominent clinical 
features of typical acute diffuse nephritis are as follow : Drops}', 
which is always present, and of a general character, involving 
the face, hands, feet, and cellular tissues in general. A very 



CHRONIC DIFFUSE NEPHRITIS. 251 

noticeable pallor steals over the patient, though less prominent 
than in the chronic form of the disease. The temperature rises 
to 100° or 102° F., and the pulse is over 100, full, resisting, and 
marked by increased tension. Headache is present, often severe, 
persistent, and most often frontal. Nausea is frequent and often 
attended by vomiting. Acute uraemia is common, often mani- 
fested by acute visual disorders, stupor, temporary paralysis, and 
sometimes convulsions. The appetite is abolished, thirst is 
prominent, and there is dull, aching pain or stiffness felt in the 
loins and tenderness upon deep pressure in the renal region. 

Chronic Diffuse Nephritis. 

This disease may be a sequel of the acute nephritis just con- 
sidered, but more often it develops insidiously from the begin- 
ning. It is more apt to result from the acute form when the 
latter is the outgrowth of scarlatina, pneumonia, diphtheria, or 
some of the acute infectious fevers. The student is advised to 
make a most careful differential study of this disease, more espe- 
cially with regard to amyloid disease of the kidney, with which 
it has since the days of Bright himself been frequently con- 
founded, with disastrous results to the treatment, since they are 
almost diametrically opposite in character. 

The Urine. — The quantity of urine, as a rule, is diminished 
in progressive chronic diffuse nephritis. Although no such 
marked reduction occurs as in acute nephritis, yet a reduction 
of 40 or 50 per cent, of the normal volume is not uncommon. 
The fluctuations of the daily quantity are marked, more so than 
in the acute disease. In the late stages the volume of urine in- 
creases, and in chronic cases tending toward secondary contrac- 
tion of the kidney the quantity of urine often exceeds the normal 
amount. This is because interstitial changes have been set up 
and the S3^mptoms tend to conform to the interstitial variety of 
nephritis. The specific gravity of the urine is below normal. 
In cases marked by unusual reduction in the quantity of urine, 
the specific gravity may rise above normal. This, however, is 
unusual, and results from concentration of the urine. With 
a normal volume of urine, and often much less, the specific 
gravity rules below 1020, and in late stages tending toward renal 



252 URINARY DIAGNOSIS. 

contraction the specific gravity of the urine often sinks to 1010 
or below. 

The color of the urine varies from pale lemon to dark brown, 
more often approaching the former than the latter color. The 
urine is always cloudy, the more so as the quantity is diminished. 
When the volume of urine is nearly normal the color is often 
very light, but the transparency is alwaj^s diminished more or 
less, the appearance of the urine being of a hazy, dirty character. 
This depends upon the invariable presence in the urine of a large 
amount of sediment, consisting of epithelium, renal casts, pus- 
corpuscles, and molecular matter. 

The urine always contains albumin, and usually in large 
quantities. In fact, albuminuria may be said to reach its max- 
imum as a symptom in this form of disease, often reaching as 
high as 3 or even 4 per cent, by actual weight. In such cases 
coagulation becomes so pronounced with reagents that an accu- 
rate estimate of the quantity b} r bulk measurement can only be 
made by lai-gety diluting the urine previous to testing. While 
the average quantity of albumin in the urine in this disease, 
therefore, ranges very high, it fluctuates markedly in different 
cases as well as in the same case from time to time. It would 
seem to maintain a fairty constant ratio to the specific gravity of 
the urine in most individual cases; more especially so when the 
changes in the specific gravity are sudden, or are observed over 
short periods of time. Thus, if the specific gravity of the urine 
be 1014 one day, while the next day it rises to 1018, a decided 
increase in the amount of the albumin is sure to be noted. These 
changes, however, are only relative ; the absolute loss of albumin 
for twenty-four hours remains pretty uniform over short periods 
of — say — a few daj^s. Any decided increase in the absolute 
quantity of albumin in these cases indicates an extension or 
aggravation of the disease. In cases characterized by great 
chronicity, more especially in those cases tending toward con- 
traction of the kidneys, the quantity of albumin in the urine 
often becomes reduced both relatively and absolutely. 

The solids of the urine suffer more or less reduction in this 
disease, urea and the chlorides most notably so. Occasionally, 
when dropsy is subsiding under diaphoretic measures, there may 



CHRONIC DIFFUSE NEPHRITIS. 253 

be a temporary increase of the solids of the urine, especially 
that of urea, which may even exceed the normal. This, however, 
is of brief duration, and, after a time, falls back again below the 
normal standard. 

The urinary sediment furnishes the key to the diagnosis of 
this disease. As already stated, the sediment is relatively large 
in quantity and consists of casts, white blood-corpuscles, epi- 
thelium, and cellular remnants. The casts are numerous and of 




Fig. 41.— Urinary Sediment in Chronic Diffuse Nephritis, showing 
Results of Fatty Changes in Progress. (After Peyer.) 

nearly all known varieties, but the most distinctive ones are the 
dark granular, broad hyaline, and more especially the so-called 
fatty casts (Fig. 41). In the more recent cases the casts may be 
less numerous, and, as a rule, the hyaline, slightly dotted, or 
faintly granular ones, as well as those dotted with cell-fragments, 
predominate. The longer the disease continues, the more nu- 
merous the casts become, and, moreover, the more predominant 
become the dark granular casts, the broad casts from the large, 
straight tubes, and the casts with fat-droplets attached to them. 



254 URINARY DIAGNOSIS. 

The fatty casts may almost be said to be characteristic of this 
condition. Red blood-corpuscles are rarely met with in this 
lesion, perhaps only in cases which have recently sprung from 
the acute form of nephritis. On the other hand, leucocytes are 
always to be found in larger or smaller numbers. A very 
marked sediment of granular debris is observed in this lesion, 
consisting of broken-down cellular elements. 

Epithelial cells from the renal tubules are to be found, some- 
times in numbers. They are less perfectly preserved than in 
the acute lesion, disorganization of structure being everywhere 
apparent. 

Leading Clinical Features. — The leading clinical features of 
chronic diffuse nephritis are briefly and concisely the following : 
First and most prominently dropsy, which is progressive, obsti- 
nate, general, and sooner or later extreme, — involving the cel- 
lular tissues and ultimately the serous cavities. Anaemia is no 
less marked and striking, palpable in the pallid, puffy face and 
dough-like extremities and body, and pale mucous surfaces 
wherever visible. Debility is prominent and progressive ; these 
patients being feeble and helpless, often bedridden. Emaciation 
is progressive, but masked by the dropsy. The appetite and 
digestion fail, owing to the charged condition of the blood with 
effete products which the kidneys fail to eliminate. Uraemia, 
when present, is of the less active or chronic order, coma and 
convulsions being rare, except at the close or the result of acute 
complications. 

Chronic Interstitial Nephritis. 

Under the above head will now be considered the diagnostic 
features of those usually slowly-advancing chronic processes, 
which ultimately terminate in granular contraction or atrophy 
of the kidneys, known as renal cirrhosis or chronic Bright's dis- 
ease. Many of the early writers seem to have confounded this 
lesion with diffuse nephritis, at least so far as to consider it the 
outgrowth of that primary lesion. We now know that while 
renal contraction is sometimes the result of long-continued dif- 
fuse nephritis, }^et the overwhelming majority of cases begin not 
only independently of that lesion, but are essential^ interstitial 



CHRONIC INTERSTITIAL NEPHRITIS. 255 

and atrophic processes from the beginning, and, moreover, are 
the outgrowth of totally-opposite conditions of the system and 
habits of life from those in chronic diffuse nephritis. The pre- 
viously robust, hearty, and overnourished are almost invariably 
the subjects of the interstitial lesion ; while, for the most part, 
the opposite class of people are more commonly the subjects of 
the other-named lesion. 

It may be premised that primary interstitial nephritis is one 
of the most stealthy and insidious of all diseases in its manner of 
approach, giving rise to few, if any, noticeable symptoms until 
in progress for a number of years, — often ten to fifteen. The 
lesions, though wide-spread, including the heart and arterial 
system, are yet almost imperceptible in their manifestations in 
the early stages ; at the same time they are slowly progressive 
and permanent in character. Notwithstanding all this, with due 
care and minute scrutiny of all the surrounding features of the 
case, interstitial nephritis may always be diagnosticated, however 
early and slight the lesion, if only attention be called to the 
matter; and the method of compassing this will now be con- 
sidered. 

In the studjr of interstitial contracting kidney it should be 
borne in mind that, as a rule, it is accompanied by a progressive 
hypertrophy of the left ventricle of the heart in at least 80 per 
cent, of the cases. While the cardiac hypertroph} 7 is in progress, 
the sjrmptoms, both urinary and general, are pretty uniform and 
invariable. If the patient survive sufficient^ long, however, the 
hypertrophied heart undergoes degenerative changes, and with 
the consequent heart-failure many of the characters of the urine, 
as well as the general symptoms, change completely. If this 
fact be kept in mind it will serve to prevent the confusion so 
apt to arise in consequence of the variability of the symptoms 
in different cases, as well as in the same case at different periods 
of the disease. 

The Urine. — In typical interstitial nephritis the urine is 
increased in quantity, is slightly paler than normal in color, 
perfectly transparent, rather sharply acid in reaction, and the 
specific gravity somewhat below the normal range. Albumin is 
usually present in small quantity ; only a few scattering casts 



256 URINARY DIAGNOSIS. 

are present, and these are of the narrow, perfectly hyaline order ; 
renal epithelium and cellular elements are rarely observable, but 
uric-acid and calcium-oxalate crystals are often to be seen under 
the microscope. The chlorides of the urine are nearly normal 
in quantity, the urea more or less deficient, and the phosphates 
are reduced considerably. 

A more minute analysis of these features shows the following- 
characters : The quantity of urine is usually increased from the 
beginning. This polyuria is maintained uniformly and pro- 
gressively until a comparatively late period of the disease, when 
heart-failure sets in and the volume of urine often then sinks 
below normal ; nor can it in such cases again be maintained reg- 
ularly up to the normal standard during the remainder of the 
patient's life. The specific gravity of the urine becomes pro- 
gressively lowered ; in the beginning a falling off of but two or 
three points is usual ; later on the reduction is more marked, 
though it never descends as low as in chronic diffuse nephritis 
or amyloid disease, but in pronounced cases it ranges between 
1010 and 1016. With heart-failure and consequent diminution 
of the volume of urine the specific gravity rises somewhat, and 
may even approach again the normal standard, after having 
remained for years constantly reduced. 

While albuminuria is the rule in this lesion, many ex- 
ceptions have been noted. The exceptions are often apparent 
rather than real, because albuminuria of interstitial nephritis is 
notoriously intermittent in character, sometimes disappearing 
for days and weeks, to return again and again, regardless of the 
stage of the disease. It is probable that if these so-called non- 
albuminuric cases were kept under constant observation albumin 
would be found in the urine in many of them some time during 
the course of the disease. This has been the experience of the 
author, although he has met with a few cases in which the urine 
was absolute!}' free from albumin throughout. So long as inter- 
stitial nephritis remains uncomplicated the quantity of albumin 
in the urine is invariably small, usually ranging below 10 per 
cent, volumetric measurement by the author's centrifugal method. 
General or local disturbances, such as " catching cold,''' 1 mild febrile 
attacks, etc., quickly increase the albuminuria. In late stages 



CHRONIC INTERSTITIAL NEPHRITIS. 257 

of this lesion associated with cardiac failure albuminuria becomes 
augmented considerably, the quantity of albumin may reach from 
30 to 40 per cent, bulk measure. In no case, however, does 
albuminuria approach the extreme grade in this lesion that it 
does either in acute or chronic diffuse nephritis. 

Both the relative and absolute amount of urea in the urine 
begins to suffer reduction from the beginning. At first it is 
slight, but as the disease advances it becomes a constant and, in 
many cases, a marked feature. It is not at all uncommon, in ad- 
vanced interstitial nephritis, to note a reduction of the absolute 
amount of urea of from 50 to 75 per cent. More or less reduc- 
tion is also to be noted of the quantity of all the urinary solids, 
the chlorides suffering the least reduction and the phosphates 
most. With regard to the phosphates in particular, a diminu- 
tion in quantity of the phosphates in the urine ma}' be regarded 
almost as constant a feature of this lesion as the presence of 
albumin. 

Casts from the renal tubules are probably always present in 
the urine in this lesion, but they are rarely numerous, some- 
times extremely sparse and difficult to find. This is due to 
the fact that they are of such delicate, hyaline, non-refracting 
character that the most careful search is necessary to detect 
them ; besides, their small numbers, rendered still more sparse by 
the accompanying polyuria, it often becomes necessary to con- 
centrate the sediment in order to find them. As the disease 
advances the casts become more numerous, and often they show 
fine granulations ; they are largely of the narrow hyaline and 
granular orders. 

The crystalline deposit in the urine in this lesion consists 
chiefly of uric acid and calcium oxalate, both of which are often 
to be noted together. For the most part these deposits are 
noticeable in the early stages of the disease. The uric acid is 
precipitated chiefly in consequence of the diminished pigmen- 
tation of the urine in this lesion, rather than in consequence of 
the excess of the former. The oxalic deposit occurs most often 
in gout}' subjects. 

On the whole, the urinary sediment in this lesion is remark 
ably small in quantity and practically free from cellular elements, 



258 URINARY DIAGNOSIS. 

save those that are common to normal urine. It is not unusual 
to find, even upon standing twenty-four hours, or eentrifugation 
of the urine, little or no sediment noticeable to the naked eye. 
Toward the termination of the disease, however, a sediment is usu- 
ally noticeable, in consequence partly of the more concentrated 
state of the urine, as well as the wider extension of the lesion. 

Interstitial nephritis renders the kidneys extremely prone to 
take on subacute or even acute attacks of nephritis upon expo- 
sure to certain causes, especially that of cold and febrile or 
inflammatory diseases. In such cases the quantity of albumin 
in the urine becomes markedly increased, the volume of urine 
diminished, and the sediment becomes more pronounced and 
approaches, in its special features, those of acute nephritis 
already described. In such cases it is necessary, in addition to 
the urinary examination, to carefully regard the history and 
general clinical features of the case, in order to diagnosticate 
the true conditions present. 

Leading Clinical Features. — In typical cases of chronic 
interstitial nephritis we may look for the following clinical 
features : The patient habitually rises at night once, twice, or 
oftener to void urine which, to the eye, appears normal in its 
transparenc}^ and nearty so in color. The pulse is always full, 
hard, and resisting to the finger, and marked by decided tension 
as measured by the sphygmograph. The second cardiac sound, 
as heard best in the second right intercostal space, within an 
inch and a half of the sternum, is always distinctly accented, — 
sharper and louder than normal. In most cases — at least 80 per 
cent. — the normal area of cardiac dullness is more or less ex- 
tended below and to the left, and, in man} 7 cases, notably if the 
lesion be advanced, this feature is very prominent. Disorders 
of vision are common some time during the course of this 
lesion, not very frequently early, but almost certain in late stages. 
Ursemic disorders are encountered during the course of the 
disease in some of the following forms : Mild post-cervical 
neuralgia is very common, almost characteristic ; diarrhceal 
attacks, which mark eliminative efforts of the sj^stem vicariously ; 
dyspnoea, which often appears of an asthmatic type; drowsiness, 
coma, and sometimes convulsions. 



CHRONIC INTERSTITIAL NEPHRITIS. 259 

Attacks of bronchitis are common and difficult to get rid 
of; winter cough of the aged frequently owes its origin to this 
cause. Acute inflammations of the pleura, lungs, or peritoneum 
are prone to be suddenly kindled and run a fatal course. Dropsy 
is absent, save in advanced cases, and then it is due rather to 
the cardiac failure than to the renal lesion. 

The early diagnosis rests upon the following points : A 
previous condition of robust health is usual ; age, over 40 years ; 
patient rises habitually at night to void urine of normal appear- 
ance ; the pulse is full and hard (never weak) ; the second sound 
of the heart is abnormally loud ; the urine is deficient in urea; 
small quantities of albumin are usually present, and l^aline 
casts are to be observed under the microscope if the sediment 
be concentrated. 

The diagnosis of the advanced lesion can scarcely be over- 
looked b}^ the most superficial observer. The plainly-observable 
hypertrophy of the heart; the presence of ursemic disorders, as 
headache, dyspnoea, visual defects, diarrhoeal attacks, and per- 
haps drowsiness at times ; together with certain changes in the 
urine, notably albuminuria, deficiency of urea, the presence of 
casts of the hyaline and granular order almost exclusive^, serve 
both to call attention to the disease and mark its special char- 
acter. 

Interstitial contracting kidney in many of its features is not 
unlike passive hyperemia of the organs. The differential features 
of the two have already been noted in connection with the de- 
scription of the latter. (See page 245.) 

Amyloid Disease of the Kidney. 
Amyloid change in the kidney is a local manifestation of a 
general constitutional defect ; moreover, this lesion is seldom 
confined to the kidneys, but nearly alwa3 r s involves the liver, 
spleen, and gastro-intestinal tract. Amyloid, or, as it is some- 
times termed, waxy degeneration, is essentially the outgrowth 
of a cachectic condition of the system, and most often follows 
in the wake of sy^philis, chronic suppurative processes, such as 
abscesses, extensive ulcerations, or necrosis. Tuberculosis is 
frequently traceable in the family histoiy of these cases. 



260 URINARY DIAGNOSIS. 

The changes in the kidneys in amyloid disease are very 
marked, and give rise to a very pronounced train of symptoms; 
the latter, upon superficial examination, might be mistaken for 
those of chronic diffuse nephritis. Both the lesions and symp- 
toms, however, are essentially and widely different in character. 
The author desires to emphasize in the strongest possible manner 
the importance, therefore, of carefully distinguishing these two 
renal lesions, since over and over again he has been a witness to 
the melanchoty results of such error. Repeatedly have these ca- 
chectic, ill-nourished subjects come under his observation in the 
last stages of the disease, who had long been consigned to the 
starvation process of a " milk diet," under the impression that 
their albuminuria was the result of nephritis. 

The Urine. — The characteristic features of the urine in typical 
amyloid lesions of the kidneys are concisely as follow : The 
volume of urine is above normal, the color lighter than usual ; 
the transparenc} T is unchanged, the specific gravity is low, albu- 
min is present in marked quantity, and the sediment is very 
slight in quantity, containing little or no cellular elements ; and 
but a moderate number of casts are present, most of which are 
of medium size and broad, Iryaline orders. 

Before considering more minutety these features of the urine 
it may be premised that the characters of the urine in this 
lesion of the kidney are exceedingly apt to fluctuate rather 
widely indifferent cases; but, notwithstanding this fact, well- 
marked diagnostic characteristics are not difficult to trace 
throughout the progress of the disease in most if not, indeed, 
in all cases. 

The quantity of urine in amyloid lesions of the kidneys rules 
above normal from the beginning, and in most cases the increase 
is decided. The volume of urine is subject to temporary periods 
of falling off, and at such periods it may fall below r the normal 
standard. These periods of temporary reduction in the volume 
of urine may often be accompanied b} T corresponding attacks of 
diarrhoea. The specific gravity of the urine is pretty uniformly 
reduced in marked cases, ranging from 1008 to 1014. Sometimes, 
however, even in cases attended by a marked degree of albu- 
minuria, the specific gravity ranges as high as 1016 to 1018, and 



AMYLOID DISEASE OF THE KIDNEY. 



261 



in such cases the prognosis is more favorable. In fact, 
cases of ultimate recovery from this disease observed 
author have, without exception, been cases attended b} 
paratively high range of specific gravity of the urine. C 
the other hand, are not infrequently met with in which the 
gravity of the urine sinks remarkably low, perhaps low 
in any other form of renal lesion, — 1006 and even 1004, 



the few 
by the 
' a com- 
ases, on 
specific 
er than 
. Such 




Fig. 42.— Waxy Casts in Urine of Amyloid Disease op the Kidney. 
(After Peyer.) 

features are, however, only met with in veiy late stages, and are 
usually associated with marked pobyuria. 

The presence of albumin in the urine may be regarded as an 
essential feature of amyloid lesions of the kidneys. The urine 
not only always contains albumin in this lesion, but the albumin 
is present in considerable, often in large, amount. The usual 
range is about 4 to 7 grammes per litre (Esbach's method), though 
it is not uncommon for it to rise to double that amount. The 
course of albuminuria in amyloid lesions of the kidney is quite 
variable as to quantity ; in the early stages it ma}^ be slight, 



262 URINARY DIAGNOSIS. 

though subject to sudden increase, and with the advent of poly- 
uria may again fall off. The urine always contains globulin in 
this lesion, often in larger quantity than that of serum-albumin. 

Some reduction of the urinary solids is usually to be noted 
in this lesion. The urea is slightly below the normal standard, 
probably due chieny to the lowered state of general nutrition, 
rather than to the influence of the lesions over the function of 
the kidneys, since uraemia is rare in uncomplicated amyloid 
kidneys. 

The casts are subject to some variation in number and variety. 
With the polyuria the casts are often vei\y scarce and almost 
exclusively of the hyaline order. On the other hand, when casts 
are comparatively numerous, so-called waxy, yellowish, refracting 
casts may be present, and occasionally dark, granular ones. The 
chief distinctive feature about most of the renal casts met with 
in this lesion is their comparatively large size and hyaline char- 
acter. 

The urinary sediment is comparatively small in quantity in 
this lesion, in fact unnoticeable, as a rule, to the naked eye, and 
it is practically devoid of cellular elements throughout if the 
disease remain uncomplicated. 

Leading Clinical Features. — Amyloid lesions of the kidneys 
appear in the wake of the so-called wasting diseases, or are often 
preceded by syphilis or some exhausting suppurative process. 
These patients appear unhealthy and plainly cachectic, except 
in a few syphilitic cases. The skin assumes a sallow or bronze- 
like tint, the tongue is nearly always heavily coated, d}^spepsia 
is prominent, and diarrhceal attacks are common. Dropsy is 
present in most cases, but exceptionally it may be absent until 
late. Uraemia is exceedingly rare. The liver and spleen become 
enlarged some time during the course of the disease in the ma- 
jority of cases. These patients are weakly, anaemic, and en- 
feebled, with small, thready pulse and cold extremities ; but 
the predominant features throughout are the disorders of the 
stomach and bowels ; dyspepsia or diarrhoea or both demand 
almost constant attention as the disease becomes advanced. 

The distinction between amyloid disease of the kidne} 7 s and 
chronic diffuse nephritis hinges upon the following points : In 



CYSTIC DISEASE OF THE KIDNEY. 263 

nephritis the urinary sediment is large in quantity, and contains 
a large number of casts, including epithelial, dark granular, and 
fatty casts, as well as those with fragmentary cellular elements 
attached. Leucocytes, cellular elements, and granular debris are 
prominent features of the sediment. Dyspepsia and diarrhoea 
are not especially prominent features, nor is cachexia a common 
accompaniment. The liver and spleen are not enlarged, but 
anaemia is very pronounced. In amyloid disease the reverse of 
the above features prevail. 

Cystic Disease of the Kidney. 

This disease is met with in two forms : (a) As a congenital 
obstructive disease, usually associated with absence of the ureter, 
or other malformation interfering with escape of urine. (6) As 
a disease of adult life, and independent of the congenital form ; 
and in many of its features allied to chronic interstitial nephritis, 
— indeed, by some authors considered a form of the latter. 

Practically, the latter form only possesses a clinical interest 
to physicians, and to this form the following considerations 

apply :— 

It is not uncommon to find C}'sts of considerable size in 
chronic contracting kidne}- as the result of distal constriction 
of the uriniferous tubes, which result in proximate dilatation by 
the urine. In the disease under consideration, however, the 
cj'stic formation, though undoubtedly the same in origin (tubular 
dilatations), yet it so greatly exceeds all other changes in the 
kidney that the organ increases in bulk sufficiently to entitle it 
to rank among abdominal tumors. The shape of the kidney is, 
in the main, retained, and the weight of the organ may reach 
from 2 to 16 pounds. The disease is almost uniformly bilateral. 
Dickinson noted but 1 case out of 26 in which the disease was 
confined to one kidney. Both the medulla and cortex of the 
organ are replaced by cysts varying in size from a pin-point 
to the size of grapes or walnuts, the larger ones being usually in 
the centre of the organ. They contain fluids which vary in 
color, some being pale straw-colored, deep-yellowish, purple, or 
bloody. In consistence the contents of the cysts may be serous, 
viscid, syrupy, caseous or almost solid, consisting of fat mole- 



264 URINARY DIAGNOSIS. 

cules, epithelium, crystals of cliolesterin, uric acid, and triple 
phosphates. The cysts do not intercommunicate or terminate 
with the large conducting tubes, calyces, or renal pelvis, but are 
essentially closed cavities. 

The Urine. — This somewhat resembles the urine in chronic 
interstitial nephritis. In typical cases the urine is albuminous, 
the quantity of albumin varying from 5 to 30 per cent, bulk 
measure. The urine is pale in color when free from blood ; of 
low specific gravity, varying from 1010 to 1015, though it has 
been noted as low as 1005. Renal casts are usually found, nearly 
always of the granular order and large size. The urine contains 
blood at intervals, and sometimes in large quantities. In one of 
the author's cases the haematuria was so severe and persistent for 
months that the patient became blanched and anaemic to an ex- 
treme degree, notwithstanding absolute rest in bed and the use 
of styptics. 

Haematuria largely contributes toward exhaustion in many 
of these cases. In most cases pus is present in the urine in 
moderate amount. The quantity of urea is markedly reduced, 
both relatively and absolutely. The phosphates are sometimes 
increased in quantity, which is rarely the case in interstitial 
nephritis. The chlorides and sulphates suffer but little change. 
Triple-phosphate crystals are frequently noted in the sediment, 
notably in late stages of the lesion, when, as is usual, more or 
less cystitis is present. 

Clinical Features. — The most prominent clinical features of 
the disease, aside from the urine, are enlargement of the left 
ventricle of the heart, without valvular disease, and increased 
arterial tension, as shown by the sphygmograph. The skin is 
pale and sallow, and cachexia is apparent. The patients are 
always adults, mostly between the ages of 45 and 60 years. 
Haematuria is prominent, recurrent, obstinate in character, and 
often profuse. There is usually tumor in renal region ; bilateral, 
though often unequal in size; soft, but non-fluctuant, and pre- 
serving the shape of the kidney. In late stages of the lesion 
there is nausea, vomiting, headaches, suppression of the urine, 
coma or convulsions, the latter being the most frequent cause 
of death. Less frequently death results from exhaustion (through 



CYSTIC DISEASE OF THE KIDNEY. 265 

renal haemorrhage), bronchitis, pneumonia, or pulmonary oedema 
attended by severe d} 7 spnoea. 

Cystic disease of the kidney is distinguished from chronic 
interstitial nephritis by the non-fluctuant swelling in the sides, 
the recurrent and often severe haematuria, and the sallow, 
cachectic appearance of the patient. From cancer it is distin- 
guished by the absence of pain and slower progress in cystic 
disease. In cancer there is rapid growth of the tumor, which is 
of nodular outline and unequal resistance. The age, in cancer, 
is either under 5 years or over 60, while in cystic kidney the 
most common age is from 40 to 55. Finally, the aspirating 
needle will determine if the tumor be cystic or of solid growth. 



SECTION X. 

DISEASES OF THE URINARY ORGANS, AND URINARY 
DISORDERS {Continued). 

Renal Tuberculosis. 

In the light of recent facts and investigations, tuberculosis 
of the genito-urinary tract, through hetero-infection, must be 
considered rare, if indeed possible. Certainly, so far as the 
kidneys are concerned, it seems out of the question. While 
careless or unclean catheterization may cause infection of the 
prostate, involving the vesicula and extending to the epidid}*mis, 
the anatonry of the urethra and the fact that tubercle bacilli do 
not multiply in the urine or possess in themselves any degree 
of motor power negative the view heretofore held b}^ some, that 
infection may occur through coitus, or the infection reach the 
kidneys or upper urinary tract through the urine. 

Tuberculosis of the kidney occurs in two distinct forms : 
(a) acute miliary tuberculosis and (b) local caseating tuberculosis 
or " scrofulous kidney.' 1 '' The miliary form is mostty met with 
in children under 10 3 T ears of age. It is pretty uniform^ bilat- 
eral, although the organs often differ in degree of infiltration. 

The caseating or scrofulous kidne}^ is most frequent in young 
and middle adult life, although it ma} T be met with late in life, 
and it is rare under 10 3 T ears of age. Scrofulous kidne} T is nearly 
as often unilateral as it is bilateral. Of the two forms of renal 
tuberculosis the miliary form is about twice as frequently met 
with as is the caseating or scrofulous kidney. Miliary tubercu- 
losis is always associated with tuberculosis in other parts of the 
organism, most often phthisis pulmonalis, tubercular meningitis, 
and tabes mesenterica. This form rarely gives rise to distinct- 
ive sj^mptoms, being merged for the most part into general 
tuberculosis, and, therefore, scrofulous kidney onty deserves 
special consideration in this connection. 

Chronic localized tuberculosis of the kidne3 T , renal phthisis, 
tubercular pyelitis, tuberculous p3 T elonephritis, or scrofulous 
(266) 



RENAL TUBERCULOSIS. 267 

kidney, as it is severally known, begins usually at the papillary 
apices, in the calyces, or renal pelvis, and from thence by the 
blood- and lymph- channels it extends to the kidney proper. De- 
posits of cheesy matter infiltrate the renal papillae, and in the 
course of a few weeks these form irregular, softened areas, which 
by progressive infiltration spread deeply inward, involving the 
parenchyma of the kidney. The organ becomes, in consequence, 
enlarged and lobulated. The renal pelvis and ureter, on the 
other hand, become contracted in consequence of thickening of 
the mucosa, and later on the ureter often becomes choked or 
blocked by softened and caseous masses detached from ulcerated 
caseating surfaces above. At the same time the tubercular 
nodules within the kidney, after reaching considerable size, 
undergo necrotic changes and break down, forming irregular, 
rudely-globular cavities. These, as they enlarge, become pyri- 
form in shape and extend until they coalesce, and at length the 
whole medulla and most of the cortex become involved. The 
destructive process continuing, the contents of the renal cavities 
at length burst into the renal pelvis and the whole organ becomes 
practically an abscess-cavity. If the ureter be pervious the 
urine washes down the debris, which present characteristics soon 
to be considered in detail. Should the ureter, however, become 
permanently blocked, dilatation and sacculation of the kidney 
result, — practically a tubercular pyonephrosis. In case one 
kidney remain uninvolved the diseased organ either becomes an 
hydronephrotic cyst or a shrunken, " putty-like " mass ; in both 
cases little, if any, of the secreting tissue proper can ultimately 
be found. The disease is usually a chronic one in character, and 
during its course neighboring organs are often involved by direct 
extension through the capsule of the~kidney, more especially the 
liver and spleen. 

The Urine. — Polyuria from tubercular irritation is probably 
the earliest urinary change. The quantity of urine is increased 
and the calls to micturate are more frequent than normal. Truces 
of albumin and a few blood-corpuscles are usually to be found 
also before destructive ulceration sets in. The urine is usually 
pale and murky in appearance, of somewhat lowered specific 
gravity, and of acid reaction. 



268 URINARY DIAGNOSIS. 

When ulcerative changes set in the urine presents the follow- 
ing changes more or less marked, according to the degree of 
degeneration in progress. The urine is of a pale, milky color, 
the transparency is diminished, the specific gravity is below 
normal; and the reaction is, as a rule, alkaline. The urine con- 
tains pus in gradually-increasing quantity. The pus is less 
variable in quantity from daj 7 to day (unless the ureter becomes 
blocked) than in most other forms of pyuria. The pus imparts to 
the urine a more or less pronounced milky appearance, whieh 
does not completely subside as in most other conditions of 
pyuria, but much of the pus remains in suspension even after 
long standing ; this is very significant of renal tuberculosis. 
The urine contains blood in rather more than 25 per cent, of the 
cases. If the blood come from the renal pelvis it is usually 
small in quantity, often unappreciable to the naked e} T e. Some- 
times very marked hematuria occurs, usually at intervals ; and 
this denotes ulcerative changes within the renal parenchyma. 
As the disease becomes advanced the urine usually becomes 
ammoniacal and markedly offensive, contains ropy mucus, and 
deposits triple phosphates, small caseous masses, and renal 
debris. The urine is albuminous, sometimes highly so ; always 
in excess of the ratio, due to contained pus and blood. 

The bacillus tuberculosis of Koch is present in the urine in 
most cases after necrotic changes set in, and its discovery is 
diagnostic. The tubercle bacillus can often be demonstrated in 
the urine by the methods already considered, though this is by 
no means so eas}^ as in the sputum, owing to the fact that they 
are relatively few and scattered in the average sample of urine. 
It is safer, therefore, when suspected, but not found by direct 
examination, to resort to cultures in gelatin after the usual 
manner and the inoculation of animals. 

Leading Clinical Features. — The leading clinical features of 
renal tuberculosis are concisel} 7 as follow : Polyuria and dysuria, 
the latter prominent and progressive. The bladder will not 
tolerate the urine, and is only free from pain or distress when 
empty. Pain begins about the middle of the act of micturition 
and continues to the close, but, as a rule, not after. Some pain 
is usual in the renal region, accompanied by tenderness upon 



RENAL CANCER. 269 

deep pressure. The evening temperature is usually from 2 to 4 
degrees higher than normal, or sometimes periods of fever occur, 
lasting for several days, followed by periods of remission. These 
patients suffer from profuse night-sweats, loss of appetite, de- 
bility, and emaciation in the course of the lesion ; while cough 
and diarrhoea are scarcely less frequent accompanying features 
of the disease. Ursemic complications are rare. 

From calculus the distinction hinges on the slow develop- 
ment and irregular degree of pyuria, which is usually preceded 
by slight hematuria in calculus. The general nutrition is better 
preserved than in tuberculosis. The pain on micturition is re- 
lieved at the close in tuberculosis, while in stone it is increased. 
Absence of temperature and constitutional symptoms charac- 
terize the progress of calculous disease, while they are prominent 
in tuberculosis. 

Renal Cancer. 

Primary cancer of the kidney may appear in the form of 
carcinoma, sarcoma, and rarely as lymphadenoma. Sarcoma is 
most frequently met with in childhood, while carcinoma is mostly 
met with after 40 years of age, the encephaloid being the most 
frequent variety of the latter, though occasionally the melanotic 
growth is met with. Primary cancer usually attacks but one 
kidney ; only exceptionally is it bilateral. Of 59 cases collected 
by Ebstein, 31 involved the right kidney, 23 the left, and 5 both 
kidneys. Encephaloid cancer of the kidney sometimes attains 
an enormous size, — 14 to 56 pounds. 

Renal cancer is more frequent in males than in females. 
Though slow of development, often remaining quiescent for 
years, when once it has begun it rapidly progresses toward a 
fatal termination, — usually within a }^ear or two. The disease 
begins in the fibrous stroma of the cortex or in the tubular epi- 
thelium ; sometimes, however, primary invasion begins in the 
lymphatics about the hilum. Wherever the primaiy lesion be- 
gins, the whole organ eventually becomes infiltrated. There is 
usually appreciable tumor after the disease becomes thorougly 
established. 

The Urine. — The most prominent feature of the urine in cancer 
is hematuria. In carcinoma this is especially pronounced, often 



270 URINARY DIAGNOSIS. 

recurring and frequently uncontrollable. In the other forms of 
cancer hsematuria may sometimes be absent throughout. Hsema- 
turia is variable, occurring sometimes early, and subsiding as the 
disease progresses, when it may disappear and not return. Again , 
the disease may become advanced before blood appears in the 
urine. As a rule, when palpable tumor is present there is 
hematuria. The hsematuria is somewhat characteristic in its 
irregular intermittency, appearing and disappearing at intervals 
without apparent cause ; while often profuse, it is yet rarely so 
excessive as to rapidly produce anaemia or exhaustion. Albumin 
is usually present in the urine in small quantity ; always present 
if there be blood. The quantity of urine is usually increased 
unless the ureters become blocked by blood-clots. Pus is present 
but in small quantity, save in advanced cases, attended by 
decided destructive changes in the kidney ; and even then the 
quantity of pus is remarkably small in amount, considering the 
extent of necrotic changes in progress. 

In carcinoma the urine frequently contains acetone, even 
before there is advanced emaciation. Frequent micturition is 
the rule, and it ma} T be so pronounced as to call attention chiefly 
to the bladder when only the kidne}^ is involved. The presence 
of organized substances in the urine, such as epithelium, casts, 
etc., are of little diagnostic value in renal cancer. Cancer-cells 
are not recognizable in the urine in this disease, and those alleged 
to have been found were doubtless transitional epithelium, which 
is often present in considerable quantit}^ if malignant disease 
invade the renal pelvis. The on\y significant feature in this con- 
nection would be the discovery of particles of the morbid growth 
with distinct alveolar structure in the urine, but in malignant 
disease limited to the parenchyma of the kidnej 1 - this is prac- 
tically unknown. 

Leading Clinical Features. — Increasing tumor is the almost 
invariable rule, which is to be looked for in the anterior lumbar 
region, between the costal arch and the crest of the ilium. If 
large the tumor approaches the umbilicus, extending upward and 
downward into hypochondrium and iliac, and even to the inguinal 
regions. The tumor is usually lobulated or presents obtuse mar- 
gins ; the lobulations often possess unequal degrees of hardness. 



RENAL CALCULUS. 271 

The tumor is nearly always fixed. Pain occurs early, usually per- 
sistent in character, though sometimes intermittent. It is most 
severe in the affected kidne}', but may be reflected to neighbor- 
ing parts. The character of the pain is dull and aching, often par- 
oxysmally increased, but not greatly aggravated by body move- 
ments. At first the pain is usually slight or even vague, and 
at times absent, becoming again severe and prolonged. From 
dull in the beginning it may later on become lancinating, 
either spontaneously or evoked by pressure, but not by move- 
ments. When tumor becomes large and presses upon the larger 
trunk-nerves, pain often extends to the chest, across median 
line, and downward to the hips and limbs, simulating sciatica. 
The pressure exerted by tumor when the latter is large often 
causes oedema of the feet and legs, ascites, and prominence 
of the superficial abdominal veins, as well as constipation, 
disturbances of the stomach, and icterus. The constitutional 
sj^mptoms include emaciation, anaemia, cachectic appearance, — 
browning or sallowing of the skin, — failure of strength and 
vitality. Uraemia is rarely, if ever, present, unless nephritis 
co-exist. Accidental or complicating features are sometimes 
added ; such as paraplegia from spinal pressure, vesical paralysis 
with retention of urine, asthmatic or laryngeal dyspnoea, and 
spasmodic cough from extension of the pathological process. 

Differential Features. — From hepatic tumors cancer of the 
kidney differs as follows : The former have no intestine in front 
of them ; the dullness upon percussion is uniform throughout. 
Renal tumors lie in part behind ascending colon, which passes 
obliquely up and to the left, giving clear note of percussion on 
lower and inner margin. Splenic enlargement presents rigid, 
thin borders instead of round and lobulated ones, and, more- 
over, as a rule, splenic tumor has more mobility, and deep per- 
cussion often elicits intestinal resonance through its substance. 
There is usually antecedent history of ague or intermittent 
fever, leucocythaemia, etc., in splenic enlargement. 

Renal Calculus. 
Calculi may originate in the secreting structure of the kidney 
— usually in the tubules — or in the renal calyx, but their develop- 



272 URINARY DIAGNOSIS. 

ment is most common within the renal pelvis ; although this 
sometimes takes place in the infundibula, calyces, or even in the 
dilated tubules, which form cavities for their location in the 
parenchyma of the organ. 

Renal calculus is usually unilateral, though man}^ exceptions 
occur to this general rule. The calculus when large is usually 
single, the smaller ones being more apt to be multiple. 

Renal calculus occurs at all ages, including intra-uterine life. 
It is, however, most common before 15 and after 50 years of 
age. In young people and children calculus is most frequent 
among the poor, while calculus in advancing life is most common 
in people of comfortable circumstances and luxurious habits. 
As a rule, the calculi in infancy is of the ammonium-urate 
variety ; that in young adults, uric acid ; that after 40 years of 
age is usually calcium oxalate. 

The Urine. — Blood appears in the urine in the vast majority 
of cases of renal calculus, and presents the following features : 
Hsematurine not profuse, but appears in repeated parox3^sms ; 
increased by exercise. The blood is intimately mingled with the 
urine ; is not bright in color, but smoky-brownish or porter- 
colored. The volume of the urine is not increased in uncom- 
plicated renal calculus, but is rather diminished. The urine is 
usually sharply acid and of high color. The above are usually 
the early features of the disease, before p}^elitis begins. After 
pyelitis is established the urine undergoes the following changes : 
Pus and mucus appear in the urine in greater or less quantities. 
More or less frequency of micturition is present, and the act 
is accompanied by uneasiness, — sometimes amounting to pain. 
This may be so pronounced as to lead to an impression that 
cystitis exists. The deposits in the urine are significant, but care 
should be taken to secure only primary deposits, — not those due 
to decomposition changes. Centrifugal sedimentation of the 
urine is the only trustworthy method of securing this. Urates 
and oxalates are often observed in the sediment, the former fre- 
quently in quantity. With the advent of P3~elitis, more or less 
phosphatic deposit is to be found in the urine. Epithelium in 
greater or less quantity is found in the sediment in advanced 
renal calculus, most often the angular and spindle form. Lastly, 



RENAL CALCULUS. 273 

the appearance of small-sized concretions in the urine often 
furnish diagnostic data of the highest value. 

Leading Clinical Features. — These consist of dull aching pain 
situated deeply in the loin, usually unilateral, and often radiating 
along the ureter toward the testicle, down the thigh, and some- 
times extending as far as the foot. The pain may be sharp and 
lancinating at times ; intensely severe paroxysms are occasional 
features (renal colic), lasting a few hours and then suddenly 
subsiding. The ordinary pain of renal calculus is invariably 
increased by exercise, either walking or riding ; it is, therefore, 
more marked in the evening than in the morning. Tenderness 
upon deep pressure anteriorly is to be found, especially if the 
calculus has excited inflammation.. Gastric disturbances are 
common, including nausea, vomiting, and periods of more or less 
disorder of digestion, — acidity, flatulence, etc. 

Differential Features. — The early stages of renal tuberculosis 
are most likely to be confounded with renal calculus. In renal 
tuberculosis there is usually tuberculous history in the family, 
and often tuberculosis may be found elsewhere in the patient, as 
in the joints and glands, and the age is usually from 20 to 40. 
Polyuria is not prominent, and renal colic is rare save late, and 
then less severe, usually not causing retraction of the testicle. 
Hematuria is more persistent, but not so much influenced by 
movements or exercise. The urine is cloudy from the beginning, 
of low specific gravity, depositing more pus, and albuminuria is 
early and more pronounced. Tubercle bacilli usually are present 
in the urine, and inoculation of animals with urine deposit induces 
tuberculosis. General symptoms are prominent, such as anaemia, 
emaciation, weakness, rapid pulse, and evening temperature, with 
night-sweats. These features are, for the most part, absent in 
stone. 

From malignant disease the distinction rests upon the more 
decided hematuria of the former, which often results in anaemia. 
Haemorrhage is uninfluenced by movement, and therefore it 
occurs at night as well as by day. 

18 



21 4 urinary diagnosis. 

Renal Embolism. 

Renal embolism consists of an impacted thrombus which has 
formed in some part of the circulatory sj^stem, — usually in the 
heart, — and is carried by the blood-current to the kidne}-, where it 
blocks one of the renal vessels. Recent endocarditis furnishes 
the most frequent source of renal embolism. As the fibrinous 
clots accumulate upon the cardiac valves, sooner or later they 
become detached in whole or in part, and those from the left 
side of the heart are liable to be carried hy the blood-current 
into either kidney. The anatomical results of embolism are 
very constant and striking, and in few organs are the}' more 
often noticed at the autopsy than in the kidneys, though they 
are not so frequently recognized during life as in some other 
locations, notably in the lungs or brain. 

The Urine. — Changes in the urine are very striking in renal 
embolism, although they are not wide-spread. Sudden and pro- 
nounced albuminuria is almost invariable. Albumin may appear 
in the urine in a few hours after the attack, but sometimes not 
for twentjvfour hours or so after impaction. The albuminuria is 
marked in degree for from two to five days ; it then gradually 
diminishes and completely disappears, or leaves only mere traces 
after two, three, or four weeks. The specific gravity of the urine 
is decidedly increased in the beginning, often reaching 1030 to 
1035 ; it gradually lowers from day to day, and the normal 
range is reached after a few days or weeks. The quantity of 
urine is decidedly diminished at first, the color is dark brown, 
and the reaction is sharply acid. Blood is usually present from 
the beginning in variable, but rarely excessive quantity. Some 
degree of pyuria is to be noted, but this is rarely pronounced. 

The urine contains casts in this lesion, often in considerable 
numbers. At first they are mostly hyaline ; later on epithelial 
casts appear, as well as those with pus-corpuscles attached to 
them. After the first five to seven days the casts become less 
numerous, they are mostly hyaline, and at length they disappear 
from the urine. It will be seen from the above features that the 
urinary changes begin abruptly, but that the urine progressively 
and steadily resumes its normal characteristics, and, in from a 
few days to three or four weeks, all manifestations of urinary 



UREMIA. 275 

disturbance pass away. The block, if aseptic, remains in the 
kidney, but ceases to become a source of renal irritation. 

Leading Clinical Features. — A previous history of endocarditis 
is the rule. The impaction is followed at once by sudden pain in 
the renal region, often accompanied by chills, which latter may be 
repeated, and some irregular action of the heart, with sense of 
precordial oppression, or clogging, and frequently dyspnoea. 
Some slight elevation of temperature is usual. If the pain be 
very severe vomiting is usual, and even some degree of collapse 
may follow. 

Uremia. 

The intimate toxic character of uraemia as yet remains an 
unsolved problem, only known to us by its results. Our knowl- 
edge of this matter, therefore, is inexact as yet, and remains for 
the chemico-physiologist to unravel. In the light of our present 
knowledge of this subject, the only conclusions that seem justifi- 
able are as follow : (a) All theories attempting to explain the 
cause of uraemia through the action of any single product or 
toxin must be abandoned as fallacious, as the toxin is un- 
doubtedly multiple, (b) The general cause of uraemia lies in the 
failure of the kidneys to excrete the urine in part, or in whole, 
and that the urine or its primary elements, as retention products, 
act as direct toxins upon the organism, evoking the symptoms 
termed uraemic. (c) That the most successful attempt at isolation 
of these products of the urine to date we owe to the investi- 
gations of Bouchard. (See Section V, page 143.) 

Uraemia may appear as an acute and rapidly overwhelming 
toxicosis, causing coma, convulsions, and death within a few 
hours; or it may linger for weeks or for months as a milder 
form of toxic disturbance, with symptoms such as somnolence, 
restlessness, headaches, nausea, attacks of diarrhoea, dyspnoea, 
visual disorders, and general disturbance of nutrition. 

The Urine. — This furnishes the key to the diagnosis of uraemia 
with great uniformity. The essential feature of the urine in 
uraemia is diminution of the absolute amount of solids, but more 
especially of urea. The quantity of urea excreted, instead of 
being 500 grains for an average body-weight, becomes reduced 
to 200 or 100, and even less than 50 grains in some cases. As a 



276 URINARY DIAGNOSIS. 

rule the activity of the symptoms bear an inverse ratio to the 
quantity of urea excreted, and therefore, in those cases attended 
by extreme diminution of the excretion of urea, the symptoms 
are sure to be pronounced and threatening so long as this con- 
tinues. The uric acid, chlorides, phosphates, and sulphates of 
the urine also suffer marked reduction in uraemia, but, with the 
exception of uric acid, these are probably of no special signifi- 
cance. As a rule the volume of the urine is diminished, and the 
degree of diminution varies through all degrees up to complete 
suppression. The specific gravity of the urine, notwithstanding 
the decreased volume, is also decreased, and sometimes markedly 
so, descending frequently to 1008 or below. Exceptions to this 
rule are noted sometimes in acute diffuse nephritis, when the 
volume of urine is reduced to a few ounces, the urea being still 
decreased both relatively and absolutely ; but the febrile con- 
dition accompanying the acute nephritis causes some increase 
in the other solids, which proportionally become excessive, and 
thus raise the specific gravity of the urine sometimes even to 
the normal range. 

With regard to the morbid constituents of the urine in 
uraemia, albumin is the most constant feature, and is present in 
all grades, from mere traces up to 2 or 3 per cent, by actual 
weight, depending upon the nature of the associated lesion. It 
should be borne in mind, however, that while albumin is usually 
present in the urine in uraemia, exceptional cases occur in which 
it is said to be absent; though this is rare. Even in those cases 
of chronic interstitial nephritis characterized by absence of albu- 
min in the urine, the exciting cause of a uraemic attack, espe- 
cially if acute, is apt to be of sufficient congestive character to 
cause, at least, mild albuminuria. It may, therefore, be repeated 
that active uraemia is extremely rare without accompanying 
albuminuria. 

The urinary sediment in uraemia includes a very wide range of 
morbid products with no very constant associated features. We 
may have casts, epithelium, pus, blood, bacteria, together with 
ciystalline or amorphous deposits of urates, phosphates, oxa- 
lates, etc. The only products that may be considered at all con- 
stant are renal casts, which are rarely — perhaps never — absent in 



URAEMIA. 27 7 

uraemia. Sometimes they are extremely sparse and may be over- 
looked without due care ; notably so in chronic interstital lesions 
of the kidney, in which their form is often limited to the small, 
perfectly-clear, non-refracting variety of casts, which are con- 
fessedly difficult to find ; but failure to find them does not, with- 
out every precaution, prove their absence. With our improved 
methods casts should be found when present. The nature and 
number of renal casts will depend upon, and correspond to, the 
character of the renal lesion present, which need not be repeated 
here. For full consideration of this subject consult Section 
VII, page 187. 

Corresponding Clinical Features. — Among the milder symp- 
toms of uraemia m^iy be mentioned d} T spepsia, flatulence, nausea, 
occasional diarrhoea, neuralgia or headaches, vertigo, dyspnoea of 
an asthmatic type, bronchial catarrh, and various nervous dis- 
turbances, such as insomnia, restlessness, mental depression, 
numbness of certain parts of the body, drowsiness, and certain 
visual disorders. 

The more pronounced symptoms include severe headache, 
usually frontal ; vomiting, extreme nervousness, twitching of the 
muscles, drowsiness; pulse increased to 100 or over, usually hard 
and tense ; temperature lowered unless some inflammatory action 
be associated; tongue coated with dry, brown fur; breath foul 
(ursemic), and often more or less profound stupor or coma, or 
convulsions, or both. 

Differential Features. — Uraemic coma may be mistaken for a 
variety of conditions, notably apoplexy, epilepsy, alcoholic or 
opium narcosis. 

Urdemic coma may be known by the following features : The 
subjects are usually young or middle-aged ; previous attacks are 
unlikely ; renal lesions are present in some form ; appearance of 
the patient is pallid, sometimes cachectic ; pulse increased to 
100 or over; the pupils tend to dilate ; the respirations may or 
may not be hastened ; breathing is stertorous and labial ; un- 
consciousness is not complete, the patient may be partly aroused 
by efforts ; a peculiar odor of breath is present (uraemic) ; the 
convulsions are of recurrent order, and, as a rule, albuminuria is 
present. 



278 DBINARY DIAGNOSIS, 

Apoplexy is differentiated as follows : The age of the patient 
is nearly always past medium life, often advanced; previous 
attacks unlikely; heredity marked; granular kidney often asso- 
ciated ; appearance of patient normal ; pulse slow, full, 60 per 

minute or under; pupils unequal: respirations slow, stertorous, 
and deeply guttural; insensibility complete and profound; 
patient cannot be aroused : hemiplegia is present. 

Epilepsy is most common under 30 years of age; previous 
attacks are the rule : the appearance of the patient is dusky, 
purple, gradually becoming paler; pulse slightly accelerated, 
small, feeble, and dicrotic ; temperature normal, or a degree or 
so above : pupils normal: respirations stertorous, guttural, un- 
steady: unconsciousness is not complete, coma of brief duration: 
great muscular relaxation present. 

Alcohol ism is common to all adult ages ; previous attacks are 
the rule. The features are suffused and bloated, the lips livid, 
and the expression vacant: pulse frequent, small, and feeble; 
temperature slightly lowered, pupils dilated; respirations are 
deep and slow ; stertor is intermittent ; breath is alcoholic ; 
vomiting is common : the conjunctivae are injected ; the features 
are swollen, and the subject can usually be partly aroused. 

Opium coma is most frequent in the young, and may be 
habitual or accidental. The features are shrunken, pallid, cya- 
notic ; expression is ghastly ; pulse usually slow and feeble : 
temperature not increased, rather lowered ; pupils contracted : 
respiration slow, shallow, and feeble, and opium may be detected 
in the breath. 

HEMOGLOBINURIA. 

Hemoglobinuria constitutes a condition characterized by the 
escape of the blood coloring elements by way of the urine, very 
little, if any. of the corpuscular elements of the blood accom- 
panying the pigmentary elements. From whatever general 
source it may originate, it is primarily due to dissolution of the 
red corpuscles of the blood, which permits the coloring matters 
to escape in solution. As an occasional phenomenon it may be 
met with in the course of certain infectious diseases, extensive 
burns, and in various forms of poisoning. In addition to this it 
occurs as an idiopathic disease of intermittent character, and to 



HEMOGLOBINURIA. 279 

such the following considerations are intended especially to 
apply :— 

This disease is most common in males, — three or four to one. 
It occurs at all ages, from 3 to 52 years, but most often between 
20 and 50. Malaria seems to be the most prominent historical 
feature of these patients, while cold is undoubtedly the most 
frequent exciting cause. 

The Urine. — The appearance of the urine in the intervals 
between the attacks is perfectly normal ; but with the attack 
its appearance becomes at once strikingly altered, apparently 
blood}-. The color assumes a dark-red, port-wine, or porter 
color, and is somewhat turbid or smoky in appearance, and de- 
posits, upon standing, an abundant chocolate-like sediment. The 
specific gravity of the urine varies from 1015 to 1030, the average 
range being slightly above normal, — 1023 to 1025. The reaction 
of the urine may be acid or faintly alkaline, and the volume is 
somewhat above normal. In most cases the quantity of urea is 
increased. The urine gives a highly albuminous reaction, and 
further testing shows the presence of globulin. 

The urinary sediment is chiefly made up of amorphous gran- 
ular matter, — doubtless disorganized blood-corpuscles, — in which 
are often to be seen minute crystals of hsematin. Casts are 
usually present, chiefly dark, granulated ones, though often, also, 
hyaline casts may be found. Many of the casts are made up of 
haemoglobin. Calcium-oxalate crystals are usually present, and 
less frequently are uric-acid crystals found. Blood-corpuscles 
are either absent or only a few scattering ones are to be 
found. The urine gives the characteristic blood reaction with 
guaiacum and ozonic ether ; even the interparoxysmal urine often 
shows the blue reaction. The spectroscopical examination of the 
urine shows the two absorption bands between Frauenhofer's D 
and E lines characteristic of oxyhemoglobin. Renal epithelium 
is often seen in the sediment, sometimes deeply stained by the 
blood-pigment. Amorphous urates are usually present in abun- 
dance, especially as the attack is subsiding. The chlorides of the 
urine are usually deficient, the phosphates and sulphates in ex- 
cess, and so-called indican is not infrequently present in consider- 
able excess. 



280 URINARY DIAGNOSIS. 

Prominent Clinical Features. — The symptoms of idiopathic 
hemoglobinuria are distinctly paroxysmal, beginning with chill, 
— sometimes continued rigors for an hour or more, — which are 
usually due to previous exposure to cold. The exposure, however, 
does not cause the disease, but merely provokes the paroxysm, as 
is proved by the fact that so long as the patient remains warm he 
continues free from symptoms. The chill is accompanied or fol- 
lowed by retching and often vomiting, as well as pain in the 
back and limbs; often with retraction of the testes. General 
malaise succeeds with yawning and stretching. Sometimes ten- 
derness in the renal region is to be elicited upon deep pressure. 
Thirst, headache, and drowsiness are frequent features, and the 
skin sometimes becomes jaundiced. In from half an hour to 
two hours the patient voids more or less port-wine-colored urine, 
The urine retains this abnormal color for two or three passages ; 
the whole attack usually being completed in twenty-four hours 
or less time ; more rarely it may continue for several days. The 
attack is often succeeded by griping pain in the umbilical region, 
and more or less pallor and weakness succeed the attack for a 
day or two. Urticaria is an occasional accompaniment of the 
disease. 

The temperature is lowered during the cold stage (96° F.), 
but often rises above normal when the chills subside. After the 
attack the patient remains apparently well for a longer or shorter 
time, — it may be for months, — until again exposed to cold. 
Nephritis is not an infrequent result ; protracted cases are char- 
acterized by repeated paroxysms. 

Chyluria. 

This disease usually arises in consequence of some lesion of 
the lymphatic system, whereby the chyle is diverted from the 
natural channels into some part of the urinary tract. As an 
idiopathic disease chyluria has heretofore been almost exclu- 
sively confined to the tropics, or to those who have spent much 
of their lives there. As such it depends upon the invasion of 
the blood and urinary tract by a parasite, — the Filaria sanguinis 
hominis, — as first pointed out by Dr. Lewis, of Bengal, and 
already described and illustrated (page 208). Besides the en- 



CHYLURIA. 281 

demic form, the disease is occasionally met with in people who 
have never lived in the tropics, and, when thus occurring, it may 
be considered an accidental condition, brought about by trauma- 
tisms or diseases which have established communications between 
the lymph-channels and the urinary passages. The accidental 
form of the disease is comparatively rare ; at least nine-tenths 
of the cases met with, even in temperate climates, are the result 
of infection in the tropics of people who previously there resided 
and contracted the disease. 

The endemic form prevails widely in the tropics, including 
especially India, China, the West Indies, — notably in Barbados, 
Trinidad, and Demarara, — also Cuba, Bermuda, Brazil, Mauri- 
tius, the Isle of Bourbon, and South Australia. The disease 
attacks indifferently both natives and foreigners, males and 
females, and shows but little preferences as to age of the subject. 
The peculiar and interesting nature and habits of the parasite 
which causes this disease have already been fully described 
(p. 209). 

The Urine. — The peculiar condition of the urine in chyluria 
furnishes the key to the recognition of the disease. The appear- 
ance of the urine is characteristically milky, and it so remains 
upon standing for days without settling, in consequence of the 
finely molecular division of the contained fat, thus permitting it 
to remain in suspension. It is unusual for oil-globules of any 
size to be found in the urine in this lesion ; indeed, the emulsion 
is so complete that only minute granular matter is seen. Some- 
times, upon standing, the fat rises to the surface of the urine 
and collects in cream-like flakes. The quantity of fat found in 
the urine in chyluria varies greatly, depending largely upon the 
quantity and quality of the food taken ; the urine of digestion 
(after food) is richest in fat, while that of fasting contains the 
least. 

If the urine be shaken with ether the fat is dissolved and the 
urine assumes its normal color and appearance. In addition to 
fat, chylous urine usually contains blood in sufficient quantity 
to impart a very noticeable pink color to the fluid. The pink 
tint is fainter than would be expected in proportion to the 
quantity of blood actually present, the opacity caused by the 



282 URINARY DIAGNOSIS. 

fat greatly obscuring the coloration due to the blood-corpuscles. 
Upon standing, however, the contrast becomes striking ; the 
bright sediment of precipitated blood is then plainly visible. 
This precipitated blood-clot becomes more pronouncedly pink 
upon exposure to the atmosphere, as first pointed out by Dr. 
Vandyke Carter. 

A notable characteristic of chylous urine is its tendency to 
spontaneous coagulation upon standing. If the urine be at all 
rich in fibrin, shortly after it is voided it will coagulate into a 
firm, vibrating, jelly-like mass resembling corn-starch blanc- 
mange. Unfortunately, sometimes coagulation takes place in 
the urinary channels, notabty the bladder, and may give rise to 
most distressing symptoms until it be dissolved or broken up 
and removed. The clots which form after the urine is voided 
often become very firm, and long retain the form of the vessel in 
which the urine stood ; if in bottles they may even have to be 
broken in order to remove the coagulum. The coagulation of 
chylous urine depends directly upon the fact of the almost con- 
stant presence of fibrin in the urine, although the quantity 
varies considerably. At times it is insufficient to cause coagu- 
lation. The quantity of fibrin present is usually in inverse ratio 
to the amount of contained molecular fat. 

The uniform presence of albumin in the urine is attested by 
the constant coagulation of the urine by heat or other albumin 
precipitants. Corpuscular elements are sometimes present in the 
urine, besides red blood-cells resembling lyuiph-cells, as well as 
large oval and rounded cells which microscopically and chemically 
evince the characteristics of epithelium. The urine is usually 
devoid of renal casts unless nephritis be excited by the disease ; 
and since the urine always contains fibrin, this would indicate 
that the lesions are not situated in the kidneys, but rather in the 
conducting channels of the urine. Filaria are sometimes found 
in the urine, especially of the tropical form of the disease, if 
sought for in the night urine. In urine excreted during the day 
they are rarely to be found, owing to the fact that the parasite 
is quiescent during the day. Pus-cells are more or less numerous 
in the sediment. 

The solids of the urine suffer some reduction owing to the 



DIABETES INSIPIDUS. 283 

drain upon the elements which go to furnish nutrition. The 
specific gravity is lowered to a moderate, rarely to an extreme 
degree, — 1016 to 1010. The urea, chlorides, and sulphates are 
usually deficient, especially the two former, while the phosphates 
are often considerably increased. It is common to find a con- 
siderable deposit of uric-acid crystals in the freshly-voided urine 
upon cooling. 

Leading Clinical Features. — The clinical symptoms are rather 
negative; dropsy, uraemia, and frequent micturition being absent. 
There is usually an indefinite dragging pain in the back and 
loins, especially preceding the attacks. Ansemia becomes more 
or less marked according to the extent and continuance of the 
drain. Loss of strength and depression are prominent features 
during the escape of chyle ; these, however, are at once relieved 
if this cease. Tuberculosis often becomes a complicating feature 
of very chronic cases. The disease pursues an intermittent 
course, — especially so the tropical endemic, — due to successive 
ruptures of lymphatics ; the accidental form is more uniform in 
its course. The duration of the disease is indefinite, but always 
chronic, lasting from ten to forty-seven years. 

Diabetes Insipidus. 

This disease has been variously designated under the terms 
diuresis, polyuria, polydipsia, and hydruria. Little or nothing 
definite is known as to the pathology of the disease ; it is not 
improbable that it is caused by a number of different morbid con- 
ditions. The disease is much more frequent in males than in 
females. It may appear at any age, but in the majority of cases 
the disease appears between 5 and 30 years of age. From the 
number of alleged causes of the disease by various authors, it is 
xery evident that nothing definite is known of the etiology, save 
in those cases that can be distinctly traced to traumatisms, intra- 
cranial growths, or other lesions of the nervous system. 

The Urine. — The chief features of the urine are : enormous 
increase of volume, lowered specific gravity, and absence of both 
sugar and albumin. The daily volume of urine not infrequently 
reaches from 15 to 40 pints. The urine is pale in color, almost, 
in fact, watery in appearance, and the specific gravity ranges 



284 URINARY DIAGNOSIS. 

from 1002 or 1003 to 1007. The reaction is feebty acid or 
neutral. Upon standing, the urine soon becomes ammoniacal 
and turbid from precipitation of earthy phosphates, and gives a 
rather offensive, fish-like odor. The urea, while proportionately 
reduced, is, in fact, absolutely increased considerably above the 
normal range. Uric acid is apparently greatly deficient, and 
it is even claimed to be often absent. The increase of urea and 
deficiency of uric acid favor the presumption that the latter 
undergoes conversion into the former. The chlorides, phos- 
phates, and sulphates are more or less increased, more especially 
the phosphates, which sometimes become greatly excessive. Al- 
bumin is usually absent from the urine, although in protracted 
cases it is often present in small quantities. Inosite is frequently 
present in the urine, as Strauss claims, merely as the result of 
irrigation of the tissues, since he succeeded in producing the 
same condition, experimentally, upon subjects by administering 
copious draughts of water. 

Prominent Clinical Features. — The most prominent symptoms 
of this disease are as follow : Inordinate, constantly-recurring 
thirst, which is only briefly quenched by copious draughts of 
water. Less constantly the appetite is increased. These patients 
are sensitive to cold and are easity chilled, the temperature being 
somewhat lowered. The tongue is dry, and more or less dis- 
comfort is experienced in the stomach ; pain and diarrhoea are 
often present. The skin is diy, pinched, and dusky. The patient 
becomes spare and weak, though, exceptionally, fair strength and 
health is maintained for years. In late stages of the disease, 
oedema of the lower extremities sometimes appears. 

Diabetes Mellitus. 
Saccharine diabetes constitutes a perverted state of the elab- 
orative functions in which certain elements which go to make 
up nutrition — notably starches and sugars — fail to reach their 
normal destinations in the economy. The S3 T mptoms evoked are 
parti}" due to lack of nutrition and partly to the damaging effects 
of the waste products (chiefly sugar) upon the tissues. The direct 
cause of the disease is an impaired functional capacity of the 
liver in its glycogenic relations. This niay, however, be induced 



DIABETES MELLITUS. 285 

through impaired nervous influences, which may be central or 
reflected. In addition, some complemental relationship exists 
between the functions of the liver and pancreas, which often 
permits lesions of the latter organ to evoke the phenomena of 
diabetes mellitus. The precise nature of this relationship is 
unknown. 

Something over 30 per cent, of the cases can be traced heredi- 
tarily. The disease is notably frequent among Hebrews. It 
attacks males twice more frequently than females. It occurs 
most often between the ages of 25 to 65, and is infrequent at the 
two extremes of life. In young people under 30 years of 
age the disease is almost uniformly progressive toward a fatal 
issue in from a few months to four or five years. If the disease 
do not appear until between 40 and 50 years of age, it is often 
more amenable to treatment ; after 50 it may usually be held in 
control by proper management. The disease is more severe 
in spare than in stout subjects, at all ages. In the young death 
is most frequent from diabetic coma, while in those advanced in 
life the end is often reached through cardiac degeneration, gan- 
grene, or exhaustion. 

The Urine. — The physical characters of the urine are character- 
istically altered in typical saccharine diabetes. The urine is light 
in color and of a greenish, rather than yellowish, tint. It remains 
perfectly transparent and froths much if poured from one vessel 
into another. The specific gravity is markedly increased, rang- 
ing from 1030 to 1045, or even higher. The reaction is sharply 
acid, and it long remains so upon standing. The quantity of 
urine is greatly increased, the increase being usually in direct 
ratio to the quantity of contained sugar. From 6 to 12 pints 
of urine are often voided in twenty-four hours, but in severe 
cases 25 to 40 pints are sometimes excreted. 

The most characteristic feature of the urine is the presence 
of sugar, which forms the index to the disease. The quantity 
of sugar varies from 1 to 8 per cent., averaging perhaps 4 or 5 
per cent. One and a half to two pounds of sugar per day consti- 
tute the highest range of sugar excreted in the more extreme 
cases, while half a pound is not uncommonly excreted in ordi- 
nary cases. The quantity of urea is markedly increased. A 



286 URINARY DIAGNOSIS. 

marked decrease in the quantity of urea may be considered as 
an unfavorable indication. The uric acid is usually deficient, 
often reaching but half the normal amount or even less. Not- 
withstanding the above fact, uric-acid crystals are frequently 
deposited from freshty-voided diabetic urine ; the deficiency of 
coloring matters and disproportion of salines permitting it to 
fall out of solution. The sulphates of the urine are not materi- 
al^ altered in quantity, probably because of the large amount 
of animal food usually eaten in these cases. The gross chlo- 
rides, like the sulphates, remain essentially unaltered in quantity, 
though often varying considerably from day to day. The phos- 
phates vary greatly according to the quantity and quality of 
food taken, but, on the whole, the tendenc}^ is toward increase. 

The urine often contains, in the advanced stages, acetone or 
an acetone-yielding substance. Diacetone is occasionally pres- 
ent in the urine, but only in serious cases, and it is usually the 
index of approaching diabetic coma. Albumin is often present 
in small quantity in chronic cases. It may be due to co-existing 
nephritis, but more often to disturbance of the renal circulation, 
impaired nutrition of the renal epithelium, or degeneration of 
the parenchyma of the kidne} T s. 

Prominent Clinical Features. — The most prominent symptoms 
are: thirst, polyuria, lowered temperature, hunger, weakness, 
emaciation, and nervous disorders. The thirst is constant, and 
seemingty unquenchable in character. Although the amount of 
water consumed is sometimes enormous, the mouth and throat 
remain dry and parched. The appetite is alwa} T s increased, at 
first sometimes inordinate, and but little appeased b} T food. As 
a result the stomach sooner or later becomes disordered under 
the strain of constant overloading, so that in late stages of the 
disease the appetite fails, and d} T spepsia follows. Constipation 
and attacks of diarrhoea are common. The mouth, tongue, and 
fauces become intensely red and congested; the gums become 
tender and shrunken so that the teeth sometimes loosen. The 
temperature is lowered, — 96° to 9*7° F. being common, but even 
a temperature of 93° F. has been observed. Chihy sensations are 
frequent ; so that these patients instinctively seek the fire and 
require extra clothing. Colds are excited upon slight exposures. 



URINARY FEVER. 287 

Periods of somnolence are common, and various nervous mani- 
festations appear, as neuralgia, cutaneous hyperesthesia, sensa- 
tions of abnormal heat of skin, sudden spells of perspiration. 
These patients become irritable, fretful, uneasy, vascillating, and 
the mind deteriorates somewhat. The sexual power declines 
or is completely lost. The skin is dry, harsh, unperspirable, 
wrinkled, and loose, causing an early aged appearance. Emaci- 
ation progresses sometimes with rapidity ; the muscles feel weak 
and tired, so that movements become laborious and exhausting, — 
these patients do not care to exercise. The pronounced and per- 
sistent polyuria produces frequent micturition, which harasses 
the patient both clay and night. Tuberculosis sometimes sets in 
in the late stages of the disease, often, however, preceded by 
bronchitis or localized pneumonia. Gangrene of the extremities 
is common in aged subjects. Cardiac enlargement, high-tension 
pulse, and degenerative changes of the heart often supervene in 
long-standing cases. 

Finally, gastric pain, dyspnoea, and more or less drowsiness 
announce the approach of diabetic coma, which quickly termi- 
nates life. 

Urinary Fever. 

Yarious names have been applied to this disease, such as 
urethral fever, catheter fever, urinary fever, shock, urinary 
poisoning, ursemic poisoning , urinary infection, — names which 
suggest the various and conflicting views held both of the 
etiology and pathology of this condition, which, indeed, still 
remain unharmonized. 

The term " urinary fever " was first emplo}^ed by Guy on to 
denote the febrile disturbance and accompanying phenomena set 
up by instrumentation of the urethra or bladder, or by opera- 
tions upon the urinary organs, or by impressions upon the 
urethra or bladder by other means. The morbid phenomena 
evoked by instrumentation of the urethra and bladder may 
become so wide-spread as to include septic inflammations of the 
renal pelvis, the kidney itself, and even pyaemia ; or it ma}' bring 
about acute uraemia, with its attendant consequences, often ter- 
minating in death. In most of these conditions some previous 
disease existed either in the kidneys, bladder, or urethra, and 



288 URINARY DIAGNOSIS. 

the instrumentation merely served to convert a chronic disease 
into an acute and often highly-dangerous condition. Much of 
the confusion in the past, and, to some extent, still existing, in 
reference to the pathology of urinary fever, has arisen from the 
mistake of describing the various inflammatory and septic proc- 
esses set up in abnormal urinary organs by instrumentation, and 
attempting to harmonize these with the temporary fever induced 
by instrumentation of the urethra and bladder. We may, for 
instance, have all the conditions present which tend -toward the 
development of septic nephritis, such as obstructive cystitis or 
ascending pyelitis. The use of the catheter under such circum- 
stances, especially in elderly men, is very apt to at once evoke 
acute (septic) interstitial nephritis, resulting in death. While 
the exciting cause in such case was instrumentation, pathological 
conditions pre-existed, and the instrumentation merely served to 
convert a chronic into an acute septic disease. 

By urinary fever, as here considered, is meant the elevation 
of temperature and accompanying symptoms evoked by the 
passage of a sound or catheter, b}^ operations or other impres- 
sions made upon the lower urinary tract, the kidneys and urinary 
organs being free from disease. 

The passage of a catheter into a healthy urethra, when the 
bladder and kidneys are perfectly healthy, may evoke symptoms 
and results of all grades, from a mere transient faintness, recov- 
ered from in a few minutes, to violent chill, elevated tempera- 
ture (103° to 105° F.j, suppression of urine, convulsions, and 
even death in from six to fortj r -eight hours. Morris has es- 
pecially pointed out that the nervous connections with the genito- 
urinary tract are so peculiarly constituted that, if a local irrita- 
tion be at all pronounced, conditions are favorable for the most 
wide-spread nervous storm to prevail over the entire sympathetic 
and cerebro-spinal systems, involving the cardiac, pulmonary, 
and renal circulations to the extent of inducing syncope, im- 
paired respiration, acute renal congestion, convulsions, and even 
death. 

But even the slighter forms of local irritation (measured b}^ the 
degree of instrumentation), as the gentle passage of a sound, are 
as likely to evoke an attack of urinary fever as operations upon 






URINARY FEVER. 289 

the urinary organs of very considerable extent, such as lithotomy 
or lithotrity. 

The Urine. — The quantity of urine is more or less dimin- 
ished in urinary fever. The diminution is usually very decided 
and even complete suppression may occur, lasting for one to 
three days. Very decided diminution is the rule ; complete 
suppression rather the exception. In cases of recurrent urinary 
fever unattended by suppression the volume of urine is much 
diminished daring the febrile period, while during the intervals 
the volume increases considerably. The color of the urine 
is increased and often presents a bloody tint. The urine is 
smoky in appearance, the transparency being more or less di- 
minished or absent. The reaction of the urine is acid and the 
specific gravity reduced. The solids are diminished, notably 
the urea. Blood is nearly always present in marked cases, vary- 
ing from microscopical quantities to frank hematuria. Albumin 
is constantly to be found in the urine ; the range, however, is 
usually moderate, — one to two grammes per litre, — although ex- 
ceptionally two or three times that amount is present, and this 
is always of grave significance. Casts may or may not be 
present. They are always associated with high grades of albu- 
minuria, and, like the latter, are of serious significance. 

Prominent Clinical Features. — After passing a catheter, or 
some operative manipulation of the lower urinary tract, in from 
a few minutes to six or eight hours the patient is suddenly seized 
by a chill of various degrees of severity, from merely chilly sensa- 
tions to pronounced and violent rigor, accompanied by chattering 
of the teeth and vibrations of the limbs or whole body. This 
is followed by pain in the back and limbs. The temperature 
rapidly rises from 2 to 1 degrees ; headache and injection of the 
conjunctiva are present, and nausea, vomiting, and even delirium 
are common. Dyspnoea and cardiac irregularity are occasionally 
to be noted. The pulse becomes rapid, hard, and tense, — vibrat- 
ing. After a time a pronounced perspiration succeeds, and with 
this the temperature lowers and more or less relief is experi- 
enced. The pulse grows less frequent and less tense ; the tem- 
perature diminishes, but thirst continues unabated. After six 
to twelve hours the fever subsides, leaving the patient weak ; but 

19 



290 URINARY DIAGNOSIS. 

convalescence, as a rule, is established in a da} 7 or two. In 
some cases the patient has a recurrence of the parox3~srn on the 
following day, or in two or three days, and these may be re- 
peated a number of times. In the absence of definite lesions 
the attacks soon subside and the patient regains his normal 
condition. 

Differential Features. — From pyelonephritis and suppurative 
nephritis urinary fever is distinguished by the sudden onset of 
the latter and the brief duration of the fever ; by the history of 
the case, such as previously healthy kidneys and healthy state 
of the bladder and lower urinary tract. 

From uraemia more difficulty is encountered in making a dis- 
tinction, since suppression may occur for several days and death 
result, at least in part, from uraemia. In urinary fever suffi- 
ciently severe to cause death, it does so more rapidly than does 
uraemia. The absence of coma and convulsions, the retention of 
consciousness, etc., exclude uraemia. Septicaemia is distinguished 
hy its slower onset, low typhoid character, and continuous pro- 
gressive course without intermission. 

Hydronephrosis. 

The above term was first emplo} T ed by Rayer to denote the 
overdistension of the kidney with urine. It is, in fact, a result 
of mechanical obstruction to the outflow of the urine, the obstruc- 
tion being located in the ureter, bladder, or urethra. This dis- 
ease should be carefully distinguished from pyonephrosis, — a 
condition also of distension of the kidney with urine plus puru- 
lent matter. It should also be distinguished from large cysts of 
the kidney the contents of which are fluid, but not urinous. 

Hydronephrosis in its pathological significance has been best 
expressed by Terrier and Baudouin as " an aseptic dilatation of 
the pelvis by urine, the flow of which is obstructed by some 
mechanical obstacle.'''' About 35 to 40 per cent, of the cases are 
congenital, the remainder being acquired. The congenital causes 
comprise twists of the ureter upon its axis, undue obliquity of 
the ureteral opening into the bladder, reduplication, valve-like 
folds of the ureteral mucous membrane, and imperforate ureter. 
The acquired causes include cancer of the pelvic organs, notably 



HYDRONEPHROSIS. 291 

of the ovaries ; hydatids and other growths within or im- 
pinging upon the ureters; calculus in the ureter; traumatisms, 
including renal dislocations, twists, etc. ; abdominal tumors, 
vesical growths involving the ureteral openings, and obstructive 
diseases of the prostate. 

The Urine. — The quantity of urine varies according to the 
degree of obstruction, and whether the disease be confined to one 
or both kidneys. In the milder forms of obstruction the quan- 
tity of urine varies greatly, there being periods of diminution 
followed by periods of increased flow. On the whole, the 
volume of urine is diminished. The urine is of low specific 
gravity, and reduced in its solid constituents, — conditions which, 
as Dickinson has pointed out, always exist with urine secreted 
against pressure. The urine sometimes contains blood, which 
is discharged with great pain (renal colic), especially if clots be 
present. Slight albuminuria is usually present, though this is 
not invariably so. The urea is markedly reduced, both relatively 
and absolutely ; the phosphates are greatly reduced in most 
cases, while the chlorides and sulphates suffer the least dimi- 
nution. Sedimentation of the urine shows excess of epithelium, 
in which the spindle-shaped and angular cells predominate. Renal 
casts, as a rule, are absent, but a few scattering pus-corpuscles 
and blood-discs are usually present. 

Prominent Clinical Features. — Dull, aching pain is usually 
present in the renal region, with some increased frequency of 
micturition. Tumor is present in most cases, gradually en- 
croaching on the median line and downward toward the iliac 
fossa. About one-fourth of the cases of single hydronephrosis 
extend beyond the median line, and in a considerable number of 
these tumor occupies a very considerable area of the abdominal 
cavity. Sudden diminution in size of tumor, coincident with 
excretion of unusual quantity of non-purulent urine, may be 
considered diagnostic. 

Yomiting sometimes occurs during periods of retention, and 
sometimes a urinous odor may be observed in the perspiration at 
such times. Constipation is a frequent result of pressure upon 
the colon ; more rarely diarrhoea may be present from the same 
cause. So long as the hydronephrosis be single and the 



292 URINARY DIAGNOSIS. 

remaining kidney be sound, there is absence of uraemic symp- 
toms. If, however, the remaining kidney be diseased or the 
hydronephrosis be bilateral, suppression of urine and uraemia 
are liable to result at any time and prove fatal. 

Differential Features. — Hydronephrosis is to be distin- 
guished from other abdominal tumors by the presence of urea 
and uric acid in the fluid withdrawn by aspiration, and by the 
abrupt diminution in the size of the tumor coincident with 
copious discharge of urine. Hydronephrosis may be confounded 
with renal cancer or cystic degeneration of the kidney. In 
hydronephrosis the tumor is evenly and distinctly fluctuant, no 
dullness on percussion being observable throughout its extent. 
The tumor, furthermore, does not conform to the shape of the 
kidney ; it is usually unattended by dropsy, hematuria, or 
cachexia. In cystic disease the tumor is bilateral, non-fluctuant, 
preserves the form of the kidney, is painless, sometimes attended 
by dropsy, nearly always associated with hematuria, and the 
tumor does not rapidly change in size. 

In cancer the tumor is unilateral, non-fluctuant, irregular in 
form, rapid in growth, attended by severe pain ; copious, recur- 
rent, and persistent hematuria occurs, and in late stages pro- 
nounced cachexia is present. 

Pyonephrosis. 

Pyonephrosis is a dilatation of the renal pelvis and calices of 
the kidney with purulent urine, or, in other words, it is hydro- 
nephrosis with suppurative inflammation added. In marked 
cases the suppurative process extends bej^ond the calices and 
results in compression, atrophy, and destruction of the paren- 
chyma of the kidney. The causes are the same as those of 
hydronephrosis plus suppurative inflammation. 

The Urine. — Pus is always present if the obstruction be in- 
complete. If complete at times, and not at others, pus will 
appear intermittently in the urine if the disease be unilateral. 
The quantity of urine voided will depend upon the degree of 
pressure exerted. If the ureter be blocked, as often occurs for 
some periods of time, the urine will be greatly diminished in 
volume during the period of obstruction. If only partly oc- 



PYONEPHROSIS. 293 

eluded, the quantity of urine, as well as that of pus, will vary 
even during twenty-four hours. If the obstruction be tem- 
porarily relieved, large quantities of urine are voided which 
contains blood and pus, while during the period of occlusion the 
urine is clear and normal in appearance, unless the disease be 
bilateral. 

In the early stages of this lesion the urine contains blood 
(sometimes only in microscopical quantity), more or less mucus, 
and epithelium and pus. The urine is usually acid in reaction, 
of low specific gravity, and contains albumin, as a rule cor- 
responding with the quantity of blood and pus in the urine. As 
the disease advances, pyuria becomes more pronounced. The 
urine is still acid, unless in very advanced cases, when saccula- 
tion of the kidney occurs, in which case it may become ammo- 
niacal. In all stages the urine is of lowered specific gravity, 
the solids more or less decreased, and micturition is somewhat 
more frequent than normal. 

Prominent Clinical Features. — The prominent symptoms of 
pyonephrosis comprise pyuria with constitutional symptoms, such 
as rigors, evening temperature, emaciation, anaemia, prostration, 
and, in advanced cases, hectic. If tumor form, it may be elastic 
and fluctuant or hard, and extend both forward and downward. 
Pain is present, varying with the size of the tumor and degree 
of fluctuation. It often appears in paroxysms of intensity, — 
renal colic. Pressure over the anterior of the tumor greatly 
increases the pain, or develops it, if not before present. On the 
other hand, lateral pressure may relieve the pain when present. 
The bowels are usually disturbed, constipation or diarrhoea being 
frequent. When the ureter becomes suddenly and completely 
blocked, sharp constitutional symptoms often follow, such as 
chill followed by rise of temperature, which may reach 103° to 
105° F. ; profuse perspirations, rapid pulse, quickened respira- 
tions, and sharp pain in the affected side. These symptoms 
usually continue for some time, and are suddenly relieved b} r 
a copious flow of urine, which had previoushy been greatly 
reduced in quantity. 



294 urinary diagnosis. 

Acute Interstitial Nephritis. 

This disease has been described under several names, viz., 
11 suppurative nephritis" "acute interstitial nephritis" " pyelo- 
nephritis" and " surgical kidney." It is, in fact, an acute inter- 
stitial nephritis with numerous points of suppuration in the 
kidney, varying in size from mere dots to large abscesses, which 
may occupy almost the entire organ. It is seldom observed as 
a primary disease ; by far the greater number of cases are sec- 
ondary and consequent to urethral stricture, prostatic enlarge- 
ment, large vesical calculi, atony of the bladder, infectious em- 
boli, or traumatisms. It sometimes complicates typhus, typhoid 
fever, diphtheria, carbuncles, pyaemia, cholera, and like infec- 
tious diseases. Obstructive diseases of the urinary conducting 
channels, with decomposing urine from retention, are strong 
predisposing as well as exciting causes. Under such conditions 
careless instrumentation of the urethra and bladder are exceed- 
ingly prone to induce acute interstitial nephritis ; hence the mis- 
applied term " surgical kidney." 

The Urine. — This is always cloudy, of pale, dirty-yellowish 
color, and of peculiarly foul odor. The specific gravity is re- 
duced, — 1016 to 1006, — and the quantity of urine is reduced. 
The reaction may be acid, neutral, or alkaline. If acid, the dis- 
ease is likely to be limited to the kidney ; but if alkaline, pj-elitis 
and perhaps cystitis also exist. Whatever be the chemical re- 
action of the urine when voided, upon standing it rapidly under- 
goes ammoniacal decomposition. The normal constituents of 
the urine are reduced in quantity, notably the urea. Albumin is 
always present in the urine, though in variable quantity, the 
amount always exceeding that due to the contained pus and 
blood. 

The urinary sediment is always abundant, and consists, for 
the most part, of pus, blood, bacteria, organic debris, epithelium, 
and usually casts. The presence of pus is an essential feature 
of the disease ; it is always present and may be very copious in 
quantity. 

The microscope reveals the presence of micro-organisms in 
abundance, and sometimes finely-formed casts of bacteria are to 
be seen. A sudden and marked increase in the quantity of 



CHRONIC PYELITIS. 295 

pus in the urine, especially if containing recognizable remnants 
of glomeruli or urinary tubules, denotes the formation of renal 
abscess. 

Prominent Clinical Features. — The commencement is marked 
by pronounced rigor or a succession of chills followed by rise of 
temperature, which in the evening may reach 103° to 105° F., 
while the morning temperature may be below 100° F. Weak- 
ness, drowsiness, flatulence, and sense of abdominal fullness 
follow. Rapid emaciation, pinched features, and dull, leaden, or 
sallow appearance succeed. In the evening the skin becomes 
hot and great thirst is present. Profuse perspiration is common ; 
the tongue may remain comparatively clean, but more often it 
becomes dry and coated with a brownish-white fur. Nausea is 
frequent, and vomiting occasionally follows. Renal pain and 
tenderness are usually absent, but considerable pain is present in 
the limbs and along the spine. In unfavorable cases the symp- 
toms continue until exhaustion succeeds or renal suppuration 
becomes established, either of which usually terminates life within 
a few days. 

Chronic Pyelitis. 

The more acute forms of pyelitis are included in pyonephrosis 
and acute interstitial nephritis, just considered. The general 
causes include the acute infectious diseases, such as typhoid, 
diphtheria, pyaemia, cholera, puerperal septicaemia, and such dis- 
eases as carbuncle. 

In addition to these we have chronic pyelitis of a more cir- 
cumscribed character, which may result from an acute attack, or 
it may be induced by less active causes, being essentially chronic 
in nature from the beginning. Chronic pyelitis is rarely a pri- 
mary disease, but is usually associated with other renal lesions 
or vesical diseases, especially septic inflammations of the lower 
urinaiy tract. 

Of the local causes gravel constitutes the most frequent 
source, which may act either by direct irritation or through 
obstruction. Tuberculosis is a frequent local cause, notably the 
form of slowly-developing cheesy nodules which set up inflam- 
matory changes both in the pelvic mucous membrane and neigh- 
boring tissues. 



296 URINARY DIAGNOSIS. 

The various obstructive diseases of the lower urinary channels 
are frequent causes of inflammation of the mucous membrane of 
the renal pelvis. These include urethral stricture, enlarged pros- 
tate, large vesical calculi, atony of the bladder, etc. The re- 
tained urine in such cases is extremeh r prone to be contaminated 
with pj^ogenic germs introduced from without. These organisms, 
upon introduction, rapidly multiply and spread, causing changes 
both in the urine and mucous structures, including that of the 
renal pelvis. These micro-organisms are, for the most part, 
micrococci, but rod-like forms or bacilli may also be present, 
both in the urine and mucosa of the renal pelvis. 

Pyelitis should not be confounded with suppurating nephri- 
tis. This is a common error, clue, perhaps, to the fact that they 
are often, though by no means always, associated ; but uncompli- 
cated pyelitis is unattended by the usual general symptoms of 
septic absorption which are present in suppurating inflammation 
of the kidney. 

The Urine. — The renal irritation consequent to pyelitis in- 
duces polyuria ; so that the volume of urine is augmented in 
this lesion. The color of the urine is pale straw-colored, de- 
scribed as " ivhey turbid" and sometimes tends toward a greenish 
tint. The specific gravity is reduced and the chemical reaction is 
usually faintly acid. Pus is present in varying quantity, but 
always the most prominent feature of the sediment (Fig. 43). 
The solids are relatively reduced owing to the polyuria, but the 
absolute solids suffer no material changes in amount. Albu- 
minuria is a constant feature of pyelitis, the quantity of albumin 
exceeding that depending upon the contained pus. The sediment 
is flocculent, of considerable volume, of greenish-yellow tint, not 
so viscid or stick}^ as in cystitis, and, as already stated, is 
chiefly composed of pus. The pus-corpuscles often exhibit tooth- 
like margins, notably so in chronic cases. They often become 
pressed together in the papillary ducts and form masses of 
round, oval, or long pings, which are considered characteristic 
of pyelitis. Epithelium is present only in small quantities. 
This lesion cannot be diagnosticated by the presence of spindle- 
shaped epithelium in the urine alone, as has been frequently 
asserted. In truth, much of the epithelium lost by the mucosa 



CHRONIC PYELITIS. 



297 



of the renal pelvis breaks clown into pus-cells and granular 
matter. Blood-corpuscles are rarely present, save when the pye- 
litis is clue to calculus, tuberculosis, growths, or entozoa. If, as 
is usually the case, the pyelitis be unilateral, the urine sometimes 
presents one or two anomalous features in reference to its chemi- 
cal reaction. Thus, the urine may be putrescent and offensive from 
decomposition, and yet remain acid. Again, it is not uncommon 
to meet with triple-phosphate crystals in the urine which gives 




Fig. 43.— Urinary Sediment in Pyelitis. (After Peyer.) 



a distinctly acid reaction. These features have been explained by 
the fact that the urine from the sound kidney overcomes the 
alkalinity of the urine from the diseased kidney as the}' mingle 
together in the bladder, and it is thus voided before it has had 
sufficient time to become ammoniacal. The triple-phosphate 
crystals met with in the urine under such circumstances often 
show evidences of their existence in acid urine in their super- 
ficial solution, their sharp angles being rounded. The urine in 
pyelitis is peculiarly offensive, — not merely ammoniacal, but 



298 URINARY DIAGNOSIS. 

rather also suggestive of sulphuretted hydrogen, — while in cys- 
titis the odor is almost purely ammoniacal. Once experienced, 
the odor of the urine in pyelitis may afterward be recognized as 
characteristic when present. This property of the urine, how- 
ever, varies from time to time, and may even be temporarily 
absent if the ureter of the affected side become blocked. 

Prominent Clinical Features. — These comprise aching, drag- 
ging pains, central in the lumbar region, but often radiating 
along the course of the ureter toward the bladder. The pain 
is not usually severe, is always increased by deep pressure by 
the finger-tips, and it may be absent at limited, but considerable, 
periods of time, and it is increased by exercise. Renal colic is 
apt to form a feature of the history of this lesion, but especially 
so when the cause is connected with stone, hydatids, tuberculo- 
sis, or cancer. Micturition is more frequent than normal, but it 
is rarely attended by pain, being rather of reflex character. 
Occasionally, when the ureter becomes blocked and retention of 
urine occurs in the affected organ, elevation of temperature 
occurs with the usual febrile symptoms. The fever is nocturnal, 
usually of mild grade, and often accompanied by cutaneous 
eruptions not unlike rotheln. 

Movable Kidney. 

The subject of misplacements of the kidney embraces three 
conditions of the organs : 1. Simple misplacements of the kidney. 
2. Movable kidney. 3. Floating kidney. 

Simple misplacement of the kidney is met with either as a 
congenital or acquired condition. Of the congenital order, the 
horseshoe kidney is most common ; the next most frequent con- 
genital malposition is above the sacro-iliac synchondrosis. The 
suprarenal bodies are often found congenitally misplaced, espe- 
cially when the kidneys are higher than normal. Congenital 
misplacement is most often unilateral, and most often involves 
the left kidney. Simple acquired misplacement may be brought 
about by pressure of adjacent organs, such as enlargement of 
the spleen or liver, or from pressure of large morbid growths. 
Tight lacing has been alleged as a frequent cause of downward 
displacement of the kidney, but this is now considered as an 



MOVABLE KIDNEY. 299 

exceptional cause. Both acquired and congenitally misplaced 
kidney may be mistaken for new growths. As a rule, misplaced 
kidney, if unattended by mobility, gives rise to no special symp- 
toms, and is only observed at the autopsy. It therefore deserves 
no extended study by the clinician. 

Movable kidney differs from floating kidney in that the former 
lies loosely between the peritoneum in front and the muscular 
wall of the abdomen behind, while the floating kidney is in- 
closed in peritoneum, which forms a " mesonephron." The float- 
ing kidney, therefore, floats within the abdominal cavity, as do 
the intestines. Movable kidney, as a rule, is acquired, while 
floating kidney is always congenital. Movable kidney is most 
common in females. The right kidney is about twelve times 
more frequently movable than the left, which is probably due to 
the weight and unyielding nature of the liver, the greater length 
of the right renal vessels, and the less firm attachments to the 
colon on the right, together with the greater right tension and 
strain in right-handed people. Movable kidney is bilateral 
about once in every twenty cases. It is most frequent from 
30 to 40 years of age, a large proportion of the cases occurring 
in women who have rapidly borne children. 

Absorption of the fatty elements of the renal capsule is now 
regarded as the most common predisposing cause of movable 
kidney, and this is borne out by the remarkable frequency of its 
occurrence in spare subjects. Lastly, movable kidney is often 
the result of dislocation from falls or blows. 

The Urine. — It has been denied by many authors that movable 
kidney produces any effect on the character of the urine. Those 
who have seen much of such cases, however, will scarcely have 
failed to observe frequent urinary disturbances, which form an 
important, almost essential, part of the pathology of this con- 
dition. The urine is often scanty, high colored, and usually 
deposits more or less sediment ; at other times it is more copious 
than normal. Hematuria is not unfrequent in movable kidney. 
The twists of the ureter attendant upon renal mobility neces- 
sarily entail more or less interference with the circulation. The 
duration and degree of this interference determine the degree of 
suppression, the discharge of blood, presence of albumin, epi- 



300 URINARY DIAGNOSIS. 

thelial denudation, and pj^elitis. Suppression of urine usually 
occurs only at short periods, because the loosening of the renal 
capsule from the posterior abdominal wall permits the renal pelvis 
and part of the ureter to also separate from the abdominal wall 
and follow the renal movements. Thus, the obstacle to the 
escape of urine is more easily overcome by pressure of retained 
urine within the renal pelvis. 

Diminished excretion (25 to 30 ounces) and short periods of 
suppression, followed by short periods of copious flow of pale- 
colored urine of low specific gravity, are common features of this 
condition, though these are not so marked as in p}^onephrosis. 
During periods of suppression mild ursemic symptoms have 
been noted; these are rarely pronounced, because the flow is 
soon restored. The urine very often contains a small amount of 
albumin, owing to the circulatory disturbances in the kidney. 

Prominent Clinical Features. — The chief clinical symptoms of 
movable kidney are : sensations of dragging weight in the side ; oc- 
casional sense of movement ; severe paroxysms of pain, like renal 
colic ; pain of a dull, aching character ; neuralgic pains in trunk- 
nerves of the affected side. Nausea and vomiting are often pres- 
ent, and may be severe. Intestinal disturbances are common, 
such as diarrhoea or constipation. Loss of appetite, weakness, de- 
bility, flatulence, emaciation, and depression are frequent features 
observable. Nearly all the symptoms are increased by move- 
ment or standing, while they are relieved bjr rest and quietude. 
Menstruation and pregnancy usually aggravate the symptoms. 
Manipulation of tumor causes peculiar sinking or fainting sen- 
sations, often attended by nausea. The tumor possesses more or 
less mobility. 

Differential Features. — Limited contractions of the recti, 
transversalis, or abdominal oblique muscles sometimes give 
impressions of smooth, oval tumors, which may even disappear 
on pressure, not unlike movable kidnej-. Anaesthesia and strong 
percussion over tumor will usually distinguish the true con- 
dition. 

A tumor of the liver, or distended gall-bladder, or a liver 
deformed from tight lacing, or an hypertrophied liver may give 
rise to similar percussion-sounds, as well as similar gastric dis- 



CYSTITIS. 301 

orders, and vague abdominal sensations and pain not unlike 
movable right kidney. Distinction is most difficult, but may be 
accomplished by palpation, urinary changes or their absence, 
etiological elements, and by results of treatment. Percussion 
cannot be depended on in these cases alone ; if the tumor can be 
completely separated from the liver by palpation, it goes far 
toward establishing movable right kidney. 

Movable spleen is distinguished from movable kidney by the 
former lying immediately beneath the abdominal wall through- 
out all movements, w r hile a kidney when pushed upward retreats 
from the abdominal wall beneath the intestines. The percussion- 
note over the spleen is, therefore, always dull, while over the 
kidney it is dull tympanitic or tympanitic. 

The distinction between uterine or ovarian tumor and mova- 
ble kidney is determined chiefly by the direction of mobility. If 
mobility can be made to extend to lumbar region without pain, 
tumor of the uterus or ovaries may be excluded. On the other 
hand, movable kidney must not be excluded by mobility toward 
the pelvis, as such tumor may exceptionally be renal. If the 
renal artery can be grasped and pulsations felt, the diagnosis be- 
comes clear. Capability of replacement of kidney with disap- 
pearance of tumor renders renal source of tumor certain. 

Cystitis. 

Much confusion has existed as to the nature of cystitis in 
consequence of the diversified classifications of this affection. 
Writers speak of purulent cystitis, hemorrhagic cystitis, cysti- 
tis of the neck, cystitis of the body of the bladder, and catarrhal 
cystitis of several grades. Acute cystitis and chronic cystitis 
are employed as denoting intensity or duration of inflammatoiy 
process, rather than the character of the lesions present, and as 
such the terms are convenient for descriptive purposes. 

In the light of modern investigations and present pathological 
knowledge cystitis is coining to be better understood and its 
signification has assumed more accurate and definite meaning. 
In all its varying phases cystitis must now be considered as a 
local bladder infection b}^ bacterial germs. Normal urine, as 
already pointed out, is an aseptic fluid characterized by the 



302 URINARY DIAGNOSIS. 

absence of septic germs, while cystitis is always associated with 
the presence of septic micro-organisms in greater or less abun- 
dance. 

The same causes which bring about local infection elsewhere 
may be looked for to explain the presence of bladder infection. 
Comprehensively considered, they include the following con- 
ditions : Weakened vitality of the tissues ; favorable soil for 
development and the presence of micro-organisms possessing 
pyogenic powers. If we consider for a moment the many con- 
ditions to which the urinary bladder is exposed, which tend to 
weaken its resisting power to the action of germs ; the many 
sources of exposure to local infection, and the favorable medium 
the urine constitutes as a culture medium for many pyogenic 
germs, it no longer seems strange that cystitis is one of the most 
frequent diseases of the urinary tract. Since the discovery of 
the micrococcus urese by Pasteur, thirty-five years ago, to the 
present time, a large number of micro-organisms have been dis- 
covered in pathological urine. Although many of these possess no 
pathogenic powers, a number of them are, without doubt, closely 
associated with cystitis in the relationship of cause and effect. 

The older theoiy, that cystitis is set up by ammonia evolved 
in the decomposition of the urine by the micrococcus urese, is no 
longer accepted. It has been conclusively demonstrated b}- 
Gruiard and Gu} T on that ammoniacal fermentation of the urine 
in the bladder takes place as a result of cystitis, and in the 
absence of the latter the former does not occur. The question, 
then, of the local etiology of cystitis must be narrowed down to 
local infection of the bladder by pathogenic germs, and the 
results of their action constitute cystitis. 

Of the many etiological factors which favor bladder-infection 
may be mentioned the following : Retention of urine, trauma, 
deep gonorrhoea, stricture of the urethra, prostatitis, calculus, 
morbid growths, exposure to cold, sexual excesses, gout, para- 
plegia, etc. 

The Urine. — Pus is present in the urine as the most essential 
feature of cystitis, its absence being proof that the bladder is 
uninflamed. The quantity of pus present depends upon the 
degree and extent of the cystitis and the length of time cystitis 



CYSTITIS. 



303 



has been established. Early in the lesion the quantity is small, 
sometimes observable only under the microscope. If the urine 
be acid the cj T stitis is recent, and the pus readily settles. If the 
urine be alkaline — ammoniacal — the pus settles in a viscid, sticky 
mass, the cystitis is chronic, often termed "chronic catarrhal 
cystitis." Blood is nearly always present in acute C3^stitis, and 
sometimes also in the chronic lesion. It is increased in quantity 




Fig. 44.— Urinary Sediment in Cystitis. (After Peyer.) 



by movements or standing. In acute cases it is due to conges- 
tion ; the quantity is comparatively small, and for the most part 
it appears at the close of micturition. In tumors and varicose 
conditions of the vessels, blood is mixed more uniformly with 
the urine, and the quantity may in such cases be large. 

The quantity of albumin in the urine is inconstant in this 
lesion. In the early course of the disease it is usually due to 
pus or blood, and consequently the amount is small. In chronic 
cases the quantity is more considerable, since denudation of the 
vesical mucous surface permits of more ready escape of blood- 



304 URINARY DIAGNOSIS. 

serum. The reaction of the urine is usually acid in the early 
course of the disease as well as in mild cases ; while chronic, 
long-continued cases are mostly characterized by alkaline urine 
from volatile alkali. Accompanying the ammoniacal changes, 
more or less copious deposits of triple-phosphate crystals are to 
be found in the urine. In addition to this, amorphous phos- 
phates are often present in considerable quantity, and less fre- 
quently, also, are urates. 

Recent cystitis differs from the chronic form as follows : In 
the former the quantity of urine is usually normal ; color is 
dark ; the reaction is acid when voided, quickly becoming alka- 
line after it is voided ; the specific gravity of the urine is usually 
normal; the appearance is turbid and smoky. Microscopical 
inspection shows the presence of vesical epithelium, pus, often 
blood, and bacteria ; and on standing a few crystals of triple 
phosphates usually are observed. 

In chronic cases the quantity of urine is about normal ; the 
color is light, the reaction alkaline, the specific gravity somewhat 
lowered, and albumin is usually present. Microscopical inspec- 
tion shows the presence of pus usually in abundance, sometimes 
blood, bacteria always, and vesical epithelium. The appearance 
of the urine is turbid, the odor is ammoniacal, and the sediment 
sticks to the glass or vessel upon standing. The micro-organisms 
most often met with in cystitis are as follow : The staphylococcus 
pyogenes aureus, albas, and citreus ; the streptococcus pyogenes; 
the urobacill us liquifaciens septicus ; and the bacillus coli com- 
munis. These are all pathogenic germs. Those most frequently 
met with are the bacillus coli communis, and next is the staphy- 
lococcus pyogenes aureus. 

Prominent Clinical Features. — Frequent micturition, pain, and 
P3^uria are the most constant symptoms of cystitis. Frequent 
micturition varies with the intensity of the disease and the sensi- 
tiveness of the bladder. In acute cystitis the desire to micturate 
is nearly continuous. The frequency is increased upon standing 
or walking, while rest tends to relieve it. The pain also varies 
according to the acuteness of the attack. The pain is often very 
intense at or just before the beginning of micturition, is more or 
less relieved during the flow of urine, while at the close of mic- 



VESICAL STONE. 305 

turition, and immediately following, for a few seconds the pain 
becomes greatly increased. The latter is most notably the case 
when cystitis is associated with stone or prostatitis. In cases of 
highly ammoniacal urine considerable pain is often experienced 
during the act of micturition. There is more or less discomfort, 
sometimes amounting to pain, with sensation of weight above 
the pubis, in cystitis, irrespective of the act of micturition. The 
bladder is sensitive to rectal touch, as well as to instrumenta- 
tion, and also to distension by injections of fluids, however 
bland they may be. Haemorrhage, if present, indicates, as a rule, 
the more acute grades of cystitis, unless in large amounts, which 
are more common in chronic forms. Constitutional symptoms 
are absent unless the disease be associated with tuberculosis, 
malignant disease, etc. 

Vesical Stone. 
The etiolog}^ and symptomatology of calculous disease have 
already been considered in detail. More than one-half the cases 
of vesical stone met with in hospital practice occur before the 
age of puberty ; about 22 per cent, occur between the ages of 
50 and 70 years ; while not above 2 per cent, are met with above 
10 years of age. The statistics of Sir Henry Thompson, as well 
as those gathered from large hospitals, substantially confirm the 
above proportions. In private practice, however, the above pro- 
portions are almost directly reversed. Thus, in Sir Henry 
Thompson's private practice the patients between 50 and 70 
years of age comprised 65 per cent, of the whole ; and those 
over 70 comprised 22 per cent, of the whole; while those under 
16 comprised less than 1 per cent. From these facts Sir Henry 
Thompson draws the following deductions : " Insufficient food, 
clothing, and fresh air, the necessary accompaniments of poverty, 
appear to encourage calculous formations among children, but 
not among adults. Habits of self-indulgence, in relation chiefly 
to diet and indolence, encourage calculous formations in early 
adult males, but the children of such parents are not affected. 
Hard physical labor and a regimen which necessarily contains 
simple diet, largely cereal, with animal food in small proportion, 
even although often associated with intemperate habits and 



306 URINARY DIAGNOSIS. 

unhealthy dwellings, discourage calculous formations among all 
classes of the community alike." The foregoing only applies to 
primary formations. 

The Urine. — Before the onset of cystitis the urine may remain 
but little changed from the normal. The quantity is normal ; the 
specific gravity is not materially altered ; the urine remains clear, 
tending to increased color, perhaps, and the reaction may be 
either acid or alkaline. The history often reveals habitual de- 
posits of red sand or white, gritty powder for months or years 
before special symptoms appear. In the early stages, when, to 
all appearances, the urine remains normal, the microscope usually 
reveals the presence of uric-acid crystals or those of calcium 
oxalate, together with scattering blood- and pus- corpuscles. 
Cj^stitis sooner or later appears, when the urine becomes cloudy 
from increased pus formation, together with the presence of epi- 
thelium, crystals of uric acid, calcium oxalate, triple phosphates, 
or amorphous urates or phosphates. If the urine remain acid 
the crystalline deposit will be uric acid or calcium oxalate, often 
both together. If the urine be alkaline the ciwstalline deposit 
will consist of triple phosphates, and the pus deposit will be 
more or less viscid and sticky. The degree of pyuria indicates 
the extent of denudation or ulceration of the mucous surface of 
the bladder. Blood is often present in variable amount, but rarely 
excessive. Albumin is always present in the urine if cj^stitis 
co-exist, and frequently in excess of the contained pus or blood. 
Micro-organisms are present also in all cases attended by cystitis, 
and for the most part of the same order. 

Clinical Features. — Pain is present as one of the most typical 
features, tending to reflection along the urethra, in the testes, or 
down the thighs. Pain is sharply increased at the close of mic- 
turition and for a few seconds afterward, especially noticed in 
the glans penis. Spasm Of the bladder is common at the close 
of micturition. The pain is alwa}-s increased by the erect pos- 
ture and b} r motion, including riding, walking, and even by turn- 
ing in bed sometimes. There is more or less increased frequency 
of micturition, augmented by motion and relieved b} T continued 
rest and recumbency. Micturition is sometimes suddenly shut 
off in the middle of the act, in consequence of the stone rolling 



VESICAL TUBERCULOSIS. 30 T 

forward over the urethral inlet. On lying upon the back this 
symptom is relieved. 

Hsematuria is the rule in this disease, the blood usually being 
clear, bright in color, and usually consists of a few drops at the 
close of micturition, the urine at the beginning of micturition 
being mostly free from blood. Sometimes haemorrhage is more 
considerable, and the blood becomes more generally diffused 
through the urine in such cases. Hematuria is increased by 
movement, as walking and riding, etc., and is relieved by rest 
and recumbency, and therefore it is always less in the morning 
and more in the latter part of the day or in the evening. To 
complete the diagnosis exploration is often necessary. This may 
be done (a) per vaginam or rectum by means of the finger ; (6) 
by means of the vesical sound ; (c) by means of the cystoscope ; 
(d) by digital examination through the dilated urethra in women. 
The most satisfactory methods are those of the sound and the 
cystoscope. 

Vesical Tuberculosis. 

Primary tuberculosis of the bladder is comparatively rare, 
and when present it invariably begins in the trigone. More 
often it results from extension of tubercular disease from the 
prostate, testes, or recto-vesical fold of the peritoneum, less 
often by infection from the upper portions of the urinary tract. 
The bladder may become infected from above either by direct 
extension of the disease along the ureter or by inoculation 
through the urine from tuberculous kidney. 

When infection occurs from surface inoculations through the 
urine from above the symptoms rapidly supervene and the dis- 
ease is acutely progressive. On the other hand, when the disease 
is primary the symptoms are more slow in development and the 
course of the disease is more apt to be protracted. 

The Urine. — Blood is usually present in the urine in this 
lesion in small amount, often transitory and recurrent, a few 
drops often following the close of micturition, as in stone. 
Sometimes, however, hematuria is pronounced, in consequence 
of ulceration about the tubercular deposits. The urine contains 
small quantities of pus from the beginning, which gradually 
increase until appreciable deposits thereof are regularly present. 



308 URINARY DIAGNOSIS. 

The urine is murky, of light color, of normal specific gravity, 
and it is usually feebly acid or neutral until it becomes ammo- 
niacal from the presence of cystitis. The urine is not especially 
offensive, although it may be ammoniacal, as just stated. 

With the occurrence of cystitis all the features of the urine 
characteristic of that disease supervene, and that in the most 
pronounced form. These include pyuria, hsematuria, deposits 
of triple-phosphate crystals, amorphous phosphates, epithelium 
in states of progressive necrosis, and micro-organisms in abun- 
dance. 

Prominent Clinical Features. — These patients are young, usu- 
ally from 15 to 30 years of age, with famiLr histories of tuberculous 
disease in some form. The early symptoms consist of increasing 
frequency of micturition for a few months, especially during the 
day. Blood appears in the urine, and with this the patient begins 
to rise at night to micturate. The pain in micturition is referred 
chiefly to the mid-penis. Sharp, vesical tenesmus becomes devel- 
oped as the disease proceeds, and in such cases the pain is 
increased at the finish of micturition. The constitutional symp- 
toms include debility, emaciation, weakness, elevation of temper- 
ature in the evening, and night-sweats. With these symptoms 
are often associated tuberculosis of the lungs, joints, glands, or 
elsewhere. 

Differential Features. — Tubercular cystitis in many of its 
manifestations resembles stone in the bladder. Tuberculosis of 
the bladder, how r ever, is more frequent in youth ; the famity his- 
tory is often tuberculous ; the irritability of the bladder is often 
marked at night, greatty disturbing the patient's rest; hematuria 
is often sudden and without apparent cause, being less dependent 
upon exercise ; there is greater relief from pain at the close of 
micturition ; pain is in mid-penis, rather than in glans penis ; 
there is persistent post-scrotal perineal pain ; the urine is light 
in color, murky, inodorous, and purulent from the beginning, and 
periods of quiescence if the s} T mptoms do not correspond to qui- 
escence and rest. In late stages evening temperature is present, 
marked constitutional symptoms arise, implication of epidid} T - 
mis is common, and knobby or shott} T feel of prostate per rectum 
points to the tubercular character of the disease. 



cancer of the bladder. 309 

Cancer of the Bladder. 

The great majority of malignant growths of the bladder are 
of the carcinomatous order. Carcinoma of the bladder usually 
begins at the base of the organ, or, more accurately speaking, at 
the lower third of the organ. It manifests a peculiar tendency 
to long remain a local disease, with little tendency of extension 
to neighboring structures. This has been explained by the 
scarcity — according to some, the absence — of lymphatics in the 
bladder-walls. 

The Urine. — The urine contains blood in the vast majority 
of these cases. Seldom being entirely absent from the urine, it 
is subject to periods of marked augmentation without any ap- 
parent exciting cause. Attacks of marked hematuria are quite 
as likely, therefore, to occur at night as during the hours of ex- 
ercise through the day. The quantity of blood is often greater 
than in almost any other disease of the urinary organs ; so that 
the bladder is liable to become partly filled with large blood- 
clots. As a rule, the quantit}^ of blood in the urine irregularly, 
but continuedly, increases as the disease advances. The color 
of the blood is usually bright red, especially when it is abun- 
dant, but if in small quantit}^ it may be dull red or brownish in 
appearance. The blood is not intimately mingled with the urine 
as it is in renal hsematuria. 

The urine often contains shreds or detached bits of the morbid 
growth, which may even be noticeable to the patient. To the 
naked eye these appear as " washed-out " bits of tissue, which 
in reality they are, and they vary in size from minute specks to 
pieces as large as a pea or small bean. Their presence merely 
indicates the presence of some growth without indicating its 
character. No trustworthy inferences are to be drawn as to the 
nature of these shreds from microscopical examination, since 
both malignant and benign growths of the bladder may present 
papillary surfaces of practically the same microscopical appear- 
ance. Since, however, such shreds are most frequently the 
product of papillomata or malignant growths, their presence 
may be considered as simply presumptive of one or the other of 
these forms of growth. 

The urine nearly always contains an abundant sediment in 



310 URINARY DIAGNOSIS. 

malignant disease of the bladder, of which epithelium constitutes 
a prominent feature. The epithelium is of small or moderate 
size, but with very large and plainly-visible nuclei. The quan- 
tity of urine remains normal, as does the specific gravity, save 
in late stages, when the latter becomes somewhat reduced. The 
urine is turbid, often brownish red, and the reaction is acid until 
cystitis becomes established ; with the appearance of the latter 
there is pyuria, ammonuria, bacteriuria, and the usual accompany- 
ing symptoms. 

Prominent Clinical Features. — Pain is a prominent and early 
symptom, usually preceding the hsematuria. The character of the 
pain is often sharp, radiating to the thighs, above the symphysis 
pubis, or in the post-scrotal region. The pain is not especially 
increased by movements. Fenwick has recently called especial 
attention to the fact, as he claims that, if the disease do not in- 
vade the trigone, pain may be practically absent until a late 
period of the disease. This may account for the occasional ab- 
sence of pain almost throughout the disease. Frequency of mic- 
turition is more or less pronounced from the beginning, and this 
is attended by pain, which is most notable just before the begin- 
ning of the flow. Rectal examination develops local tenderness 
and patches of induration. 

Benign Vesical Growths. 
The chief varieties of benign growths met with in the bladder 
are papilloma, myxoma, and myoma Of these, papillomata are 
by far the most frequent. These consist of proliferations of the 
natural structure of the vesical mucosa, forming papillae or pro- 
trusions covered with cylindrical epithelium. Sometimes these 
papillae are long and slender and float in the urine in numerous 
filaments from a common base or stalk. Examined in a dry state 
they collapse and form a soft, " strawberry -like " mass. The base 
or pedicle always contains more or less fibrous tissue, and usually 
some non-striped muscular fibres. Sometimes the growth ex- 
pands to form a polypoid-like mass of more decided firmness, or 
it may have a wider attachment to the bladder. Again, it some- 
times appears expanded into several bunches not unlike cauli- 
flower. When the fibrous elements are numerous the structure 



BENIGN VESICAL GROWTHS. 311 

is more dense, and this form has been termed " fibrous papil- 
loma. 11 The latter are, for the most part, tumors of some con- 
siderable solidity, and often have comparatively limited papillary 
margins. 

The myxoma, or simple mucous polyp, is rarely met with in 
the bladder ; thus far, only in childhood. Sometimes it is con- 
genital. The growth is that of fibroid undergoing mucoid trans- 
formation. This growth is single, pedunculated in form, and 
resembles the ordinary nasal polypus. 

Myoma is only occasional^ met with in the bladder. It is 
usually of moderate size, with wide base, round or oval in form, 
rather firm in consistence, and chiefly made up of muscular fibre, 
evidently the outgrowth of the muscular coat of the bladder. 
The last two described growths are so uncommon in the bladder 
that for practical purposes papillomata only require special con- 
sideration. 

The Urine. — The most important feature of the urine in 
papilloma of the bladder is the presence of blood, — hematuria. 
This occurs early, and at first in paroxysms, followed by more or 
less lengthy intervals of absence. Commencing insidiously, often 
appearing in the form of small dark clots, " like flies ," appearing 
and disappearing alternately for a few days at each time ; or 
again, the urine, instead, may appear slightly blood-stained, or a 
little clear blood may appear at the close of an otherwise mictu- 
rition of clear urine ; or, again, the whole urine voided may appear 
bloody, — dark " coffee-colored." The hematuria usually presents 
these various tj^pes in succession, without other prominent feat- 
ures, for long periods of time, — often for years. Sooner or later, 
however, attacks of more or less profuse haemorrhage occur and 
recur as the growth increases. The blood is not of pronounced 
arterial color, but more inclined to darker shades. Aside from 
the presence of blood in the urine, the latter is not otherwise 
especially altered in its physical characters • the specific gravity 
and volume remain about normal ; the solids are relatively and 
absolutely unchanged ; and the urine remains acid, though often 
feebly so, until late stages, attended by cystitis, when the reaction 
may become alkaline. 

The urine contains considerable sediment of a finelv-flocculent 



312 URINARY DIAGNOSIS. 

nature, brownish red in color for the most part, and contains 
blood-corpuscles, more or less pus, epithelium, and often ragged 
shreds of tissue. The deposit of epithelium from the vesical 
mucosa is a prominent feature of the sediment, often exceeding 
that in any other condition. With regard to the shreds often 
voided with the urine in these cases, it was formerly held that 
microscopical examination of these readily established the nature 
of the growth. Unfortunately, however, more extended experi- 
ence has shown that, while the epithelial character of these 
pieces is easily enough recognized, yet, in consequence of the fact 
that any bladder-growth, benign or malignant, may possess a 
peripheral epithelial fringe, no positive deductions can be drawn 
from their recognition. We are only able to say, presumptively 
from these, that papilloma is most probable, because it is most 
frequently attended by the appearance in the urine of those 
structures recognized as epithelial formations. 

Prominent Clinical Features. — The most prominent symptoms 
are long duration of hematuria without marked pain or other 
associated symptoms. In other words, hematuria precedes, for 
longer or shorter periods, vesical symptoms, such as pain and fre- 
quent micturition Some slight increased frequency of micturition 
develops after a time, with tendency to increase with the progress 
of the disease. Pain is scarcely ever a pronounced feature of 
the disease, usually only so when obstruction occurs from clot 
or growth situated near the margin of the urethra, when it may 
stop the flow of urine. In cases of this order tenesmus, frequent 
micturition, and pain become prominent, and may even precede 
the hematuria. The general condition of the patient remains 
normal, save, perhaps, anaemia, which is apt to result to a greater 
or less extent, according to the amount of the hematuria. 



SECTION XL 

THE URINE IN OTHER DISEASES. 

Simple Pyrexia. 

Certain changes in the character of the urine in pyrexia are 
sufficiently constant to merit the term " pyre xial urine " often 
emploj^ed. Generally speaking, these comprise diminution in 
quantity or, more accurately speaking, deficiency of water ; 
increased color, due to increase of pigment, both relative and 
absolute ; increased acidity, and high specific gravity. In addi- 
tion to these physical changes in the urine, provided no acci- 
dental circumstances interfere, more important changes take 
place in the composition of the urine. Among the most promi- 
nent of these changes is a decided increase, both relatively and 
absolutely, of the nitrogenous elements, viz., urea and uric acid. 
Since, for the most part, but little food is taken in pyrexial 
states, and the urea and uric acid rise considerably above the 
healthy range, we must conclude that the pyrexial state entails 
a more or less pronounced waste of tissue. While the amount 
of uric acid excreted varies in different forms of pyrexia as 
well as in different cases of the same fever, it is undoubtedly 
more uniformly increased than is any other urinary constituent. 
This increase of uric acid is proportionately independent of 
urea, which seems somewhat paradoxical considering that they 
are both derived from the same tissue-base. In addition to the 
increase of uric acid and urea, hippuric acid is often present in 
the urine in large quantity as a consequence of the pyrexial 
state, indicating, in all probability, a disturbed function of the 
liver. 

The increased excretion of pigment is chiefly due to the de- 
structive metamorphosis of the red blood-corpuscles, the latter 
being a well-known result of nearly all forms of fever. As might 
be expected, considering the excess of uric acid and urea, the 
sulphates are also markedly increased in pyrexia, constituting 

(313) 



314 URINARY DIAGNOSIS. 

another evidence of the destructive metamorphosis of nitrogenous 
(sulphur-holding) tissues. 

The chlorides and phosphates, as a rule, are reduced, both 
relatively and absolutely, in pyrexia. "With regard to the former 
the diminution is probably due, at least in part, to retention ; but 
as regards the phosphates (save in cases of acute inflammations 
of the nervous or muscular tissues) there is undoubtedly de- 
ficient excretion. 

As a whole, then, pyrexia entails an excessive excretion of 
solids by the urine. This excessive excretion begins with the 
onset of fever, and usually maintains a parallel ratio with the 
temperature ; in short, the presence of the latter invariably 
implies the former. The urine often contains a small percentage 
of albumin in simple pyrexial conditions, and the same may be 
said of acetone. 

The urinary sediment in pyrexia is often' considerable in 
amount, and consists of uric-acid crystals, urates, sometimes 
scattering hyaline casts, a few leucocytes, and epithelium. Aside 
from the modifications of the above features of the urine by special 
forms of fever, typical pyrexial urine is subject to certain vari- 
ations through certain special circumstances, as follow : When, 
during the course of a fever, an organ becomes the seat of disease, 
where tissue-changes furnish special urinary products, the prod- 
ucts may appear in the urine in excess. As examples, note the 
increase of phosphates in the urine in inflammatory diseases of 
the nervous system, and the increase of bile-acids in hepatitis. 
The overaction of other eliminating organs may disturb the 
type of febrile urine. Thus, the diarrhoea of typhoid fever 
modifies the character of the urine, as likewise does the sweat- 
ing stage of intermittent fever. These are a few of the influ- 
ences that may produce special variations of the febrile type of 
urine to a limited degree; but. on the whole, the general py- 
rexial characters stand out with sufficient prominence for general 
recognition. 

It may be stated, as a general rule, that the amount of tissue- 
metamorphosis, as indicated by the excretory waste in the urine 
in fevers, constitutes a good indication of the severity of the 
disease. — often, indeed, better than the thermometer or pulse. 



ACUTE INFECTIOUS DISEASES. 315 

Upon subsidence of pyrexia the urine assumes directly the 
opposite characters of the pyrexial state. The chlorides become 
increased, while the urea, uric acid, phosphates, and pigments 
are below the normal range. The volume of urine is increased. 
In short, everything points to delayed metamorphosis, conserva- 
tion of tissue, and repair. 

Acute Infectious Diseases. 

Typhoid Fever. — The quantity of urine is diminished about 
50 per cent, during the febrile stage of typhoid, and the volume 
gradually rises to normal in the third, fourth, or fifth week. 
The specific gravity of the urine ranges from 1025 to 1030, 
occasionally reaching as high as 1040. The quantity of urea is 
increased 25 per cent, or over; as high a range as 18 grammes 
per day has been recorded. In cases of marked splenic enlarge- 
ment, copious haemorrhages, and complicating nephritis the 
quantity of urea becomes lessened instead of increased. The 
chlorides suffer marked reduction, especially during the first 
week, but they gradually increase as convalescence approaches, 
while with urea this order is reversed. The uric acid is uni- 
formly increased, the increase being relatively greater than that 
of urea. The gross amount of uric acid increases usually until 
about the end of the second week, when it reaches about double 
the normal range. Deposits of urates are common. The phos- 
phates are somewhat diminished, and the pigments are increased 
relatively and absolutely. The reaction of the urine is sharply 
acid when voided, but often rapidly turns alkaline upon stand- 
ing, owing to ammoniacal transformation of the large output of 
urea. 

Albumin is present in the urine in a large proportion of the 
cases of typhoid fever, probably in the majority. Few observers 
place the proportion less than 20 per cent, of the whole, while 
some claim to have found it in nearly all cases. The author's 
observations lead him to conclude that albuminuria is present in 
from Y0 to 80 per cent, of all cases of typhoid. The quantity 
of albumin in the urine is usually small ; but occasionally it is 
decided in quantity, and is attended by nephritis. In such cases 
the prognosis of the disease is alwa} r s to be considered grave. In 



316 URINARY DIAGNOSIS. 

most cases the albuminuria is temporary, setting in soon after 
pyrexia becomes established and subsiding soon after the latter 
disappears. In a very considerable proportion of the cases, 
however, — larger than has been generally supposed, — albumin- 
uria fails to subside with pyrexia, and becomes permanent. 
Leucin and tyrosin are usually to be found in the urine in 
typhoid, although in no very decided quantities. 

Renal casts, epithelium, and blood are frequently seen in the 
urine. Indeed, with regard to casts, it is probable that they are 
nearly always to be found during the first and second weeks, if 
carefully sought. Peptone is often present in the urine of 
t3 r phoid, especially in the more severe types of the disease. 

Thanks to Ehrlich, the diagnosis of typhoid fever is now 
rendered almost as certain by the urine as is pulmonary tubercu- 
losis b}^ the sputum. The diazo reaction of Ehrlich met with 
many unbelievers at first, as to its reliability as a diagnostic feat- 
ure of this disease, but overwhelming clinical evidence is now 
available to prove its undoubtedly great diagnostic value. The 
following original claims of Ehrlich in reference to this reaction 
in the urine may be said to have been amply confirmed. " The 
reaction is found in typhoid fever after the fourth or fifth day, 
and if absent the diagnosis is doubtful. If the reaction be 
slight, and only found for a short time, the case will usually be 
very mild. In simple febrile intestinal catarrh, chlorosis, lrv- 
draemia, diabetes, and in diseases of the brain, spinal cord, liver, 
and kidneys, the reaction is never obtained. The reaction is 
obtained occasionally in phthisis pulmonalis, rarely in measles, 
pyaemia, scarlet fever, and erysipelas." 

" The diazo reaction in typhoid has no dependence upon the 
height of temperature, nor is it influenced by the medication. 
The morning and evening urine give the same intensity of reac- 
tion. If the reaction cease in the second or third week, the rule 
is that the fever will early decline and the further course of the 
disease be mild. On the. other hand, long-continued reaction 
indicates severity and long continuance of the disease. If relapse 
occur, the reaction returns if it has previously disappeared." 

The importance of the subject justifies a repetition of the 
essentials of the test, especially since it is strongly probable that 



ACUTE INFECTIOUS DISEASES. 317 

much of the diversity of views as to the value of the reaction in 
typhoid fever has arisen in consequence of faulty methods in 
performing the test. 

The principle of the test depends upon' the fact that diazo- 
sulphobenzol unites with certain aromatic substances met with 
in the urine in typhoid, which form analines. The diazo- 
sulphobenzol being unstable, Ehrlich obtains it fresh for testing 
by keeping sulpho-anilic acid in solution with hydrochloric acid. 
To this solution sodium nitrate is added, which liberates HN0 2 
and forms diazosulphobenzol. A full description of the test 
and the proper method of its manipulation are described on 
pages 134 and 135. 

Scarlatina. — The urine in scarlatina assumes the usual febrile 
characters, more or less marked in proportion to the degree of 
pyrexia present. During the first week the volume is reduced, 
the urea and uric acid are increased, and sediments of urates are 
precipitated. The chlorides are often decidedly reduced. From 
the sixth to the eighth day, if the disease proceed favorably, the 
urine becomes abundant, pale in color, and the general characters 
approach the normal standard. 

But the urine in scarlatina should always be the subject of 
special observation, in consequence of the fact that it is often 
especially affected in this disease. This is due to the frequent — 
almost invariable — implication of the kidneys some time during 
the course of the disease. Recent observations on an extensive 
scale indicate that nephritis exists in scarlatina, either in acute 
form or in mild, evanescent attacks, almost as constantly as the 
rash or the angina. The number of acute cases of nephritis 
attended by dropsy and high grades of albuminuria in scarlatina 
is estimated as about one in every six cases met with, 1 though 
the proportion varies greatly in each special epidemic of the 
disease. 

As a rule, albumin appears in the urine about the fifth to the 
eighth day, usually subsiding within about nine da} r s if the dis- 
ease proceed favorably. The quantity of albumin in the urine 
is subject to the widest variation, sometimes amounting to mere 

1 See section on "Scarlatinal Nephritis" in Brig-ht's Disease and Allied 
Kidney Affections, by the author. Lea Bros. & Co., Philadelphia, 1SS6. 



318 URINARY DIAGNOSIS. 

traces, while, again, the urine becomes almost solid with albu- 
minous coagulum when boiled or treated with albumin precipi- 
tants. A few cases are on record in which both nephritis and 
dropsy were present in scarlatina, while albumin was absent from 
the urine. 

Casts are almost invariably to be found in the urine if care- 
fully sought for. In cases proceeding favorably the casts are 
chiefly hyaline, often preceded by the so-called cylindroids of 
Thomas. If nephritis become established, the sediment contains 
the usual elements characteristic of that lesion, more or less 
pronounced in proportion to its grade. Thus, we may meet with 
epithelial and bloody casts, as well as granular, in chronic cases. 
In addition to these, free blood-corpuscles and often large 
showers of round epithelium are observable. As occasional 
features, the urine in scarlatina has been found to contain sugar 
in small amount, haemoglobin in severe — usually malignant — 
cases, and sometimes peptone or, more accurately speaking, 
deutero-proteose, which is usually taken for peptone. 

Albuminuria sometimes subsides during the early course of 
scarlatina, to re-appear later with nephritis. If acute nephritis 
of pronounced t} T pe occur in scarlatina, it usually appears about 
the eighteenth to the twenty-fourth day ; more rarely it arises in 
the latter part of the second week ; more rarely still during the 
fifth week. 

Cholera. — During the algid stage of cholera the urine is more 
or less completely suppressed. This is due, in the main, to 
collapse, — weakened circulation, — perhaps to some extent, also, 
to thickened blood and exudation into the renal tubules. After 
the cold stage is passed the volume of the urine slowly increases, 
or it may remain suppressed ; in the latter case the patient dies 
comatose. If the secretion of urine become re-established, it 
usually does so during the third day from the attack, — forty- 
eighth to the seventy-second hour. The quantity of the first 
urine is small, gradually increasing if the patient recover ; and 
on the fifth or sixth da} T the volume reaches the normal range, 
or often considerably above. The specific gravity of the urine 
at first, upon re-appearing, is below normal, — often 1006 or 1008. 
It may fall still lower at first, but gradually rises to normal as 
convalescence is established. 






ACUTE INFECTIOUS DISEASES. 319 

The quantity of urea in the urine is greatly reduced in 
cholera, — in fact, during the first day it may amount to but 
2 or 3 grammes, and Bigbie even found it absent. It usually 
increases somewhat on the second day, and in favorable cases it 
increases on the third to the sixth day to considerably above the 
normal range. The prognosis may be considered favorable in 
proportion to the amount of urea excreted in cases which have 
passed the algid stage. Uric acid is usually present, though in 
reduced quantity. It often falls out of solution in a colorless 
state, owing to the absence of pigment in the urine. The phos- 
phates are greatly reduced in the first urine passed ; but, like 
urea, they become markedly increased with the re-establishment 
of the urine, and for several days even considerably exceed the 
normal amount. The chlorides at first are absent, or nearly so ; 
after the fourth or fifth day they gradually return, and increase 
to, but rarely very much above, normal. The increase of chlo- 
rides is considered as even more favorable a prognostic sign 
than that of urea. As the urine becomes re-established its 
acidity becomes greatly increased. The normal urinary pig- 
ments are nearly absent for the first two days, gradually return- 
ing by the sixth day or so to the normal range. The first urine 
voided in all cases contains so-called indican — indoxyl-potassium 
sulphate — in marked quantities. Indeed, before the isolation of 
the cholera bacillus the presence of this substance in the urine 
was by many considered the best diagnostic indication of cholera 
where the symptoms were so mild as to cause doubts as to the 
nature of the disease. Our knowledge of so-called indicanuria, 
however, has so far increased that we know it is not uncommon 
in intestinal catarrhs of various kinds, as well as in certain 
general diseases attended by pronounced albuminous transform- 
ation. 

The first urine passed in cholera almost invariably contains 
albumin. So constant is this the case that if the urine were 
always free from albumin in other forms of diarrhoea, cholera 
might almost be diagnosticated by the accompanjang albumin- 
uria. As a rule, the albuminuria of cholera is of comparatively 
brief duration, subsiding within a week after its appearance. 
There is no doubt, however, that the albuminuria sometimes pur- 



320 URINARY DIAGNOSIS. 

sues an acute course, accompanied by nephritis, which latter is 
the direct cause of death by ursemic coma. As a general rule, 
the quantity of albumin in the urine is proportional to the degree 
and duration of the algid stage. 

Renal casts are invariably to be found in the urine of cholera 
patients, as well as large deposits of epithelium. With these, 
blood-corpuscles and uric-acid ciystals are usually found. Later 
on, calcium-oxalate crystals are deposited, either alone or asso- 
ciated with amorphous urates. 

Diphtheria. — The urine in diphtheria is decidedly reduced in 
volume, of high specific gravity, of sharply-acid reaction, and it 
deposits a copious sediment of uric acid, amorphous urates, ox- 
alates, and sometimes phosphates. The urine contains albumin 
in over 50 per cent, of the cases of diphtheria, varying in quan- 
tity from mere traces to the most pronounced types of albumin- 
uria. The albumin usually appears early in this disease. If of 
mild grade it sometimes subsides temporarily, and may occur 
even repeatedly. There is no doubt that the kidneys become im- 
plicated in many of these cases, but the tendency to spontaneous 
recovery from nephritis seems greater than in scarlatina or pneu- 
monia. The quantity of urea is largety increased, and this con- 
tinues throughout, unless the function of the kidneys becomes 
much crippled in consequence of associated nephritis. At the 
height of the disease the quantity of urea is often double the 
normal range. Renal casts are frequently present in the urinary 
sediment; less often, blood. Pus sometimes appears in con- 
siderable quantity as a consequence of pyelitis, which is often 
evoked by this disease. 

Variola. — In small-pox the urine assumes the usual typical 
features common to pyrexia, which continue until about the 
twelfth day. The urea is moderately increased, and reaches its 
highest average with the highest temperature. Even in the ab- 
sence of marked temperature and upon a spare diet the urea is 
still above the normal range. The uric acid is excreted pretty 
uniformly in excess throughout the course of the disease, and 
deposits of urates are constant. The chlorides are somewhat, 
though not decidedly, reduced. The sulphates suffer slight re- 
duction, though to no marked degree, probably only consequent 



ACUTE INFECTIOUS DISEASES. 321 

to the lessened quantity of food ingested. The pigment is very 
considerably increased. 

Albumin appears in the urine in about 30 per cent, of the 
cases of small-pox. It usually appears at the height of pyrexia, 
though in severe cases it often appears at the onset of the dis- 
ease. As a rule, albuminuria is only temporary in variola, the 
tendency to leave behind serious nephritis being comparatively 
slight, although such results sometimes occur. The presence of 
bile-pigment in the urine is a frequent and noteworthy fact first 
observed by Schonlein in these cases. In malignant forms of the 
disease the urine contains haemoglobin. In less severe cases 
hsematuria is not uncommon, and often of pronounced degree. 
Casts, epithelium, and other evidences of nephritis are to be 
found in the urinary sediment in cases associated with albu- 
minuria. 

Yellow Fever. — The quantity of urine is markedly diminished 
from the onset of this disease. In many cases it becomes nearly 
or even quite suppressed, and in such cases all the manifestations 
of uraemia follow. The reaction of the urine is usually acid 
throughout the first stage, and becomes alkaline during conva- 
lescence. The color of the urine varies : it may be bright yellow, 
dirty orange-colored, greenish brown, olive black, or sometimes 
red from the presence of blood. The urine becomes albuminous 
almost without exception, and very often highly so. A very 
close relationship undoubtedly exists between the more serious 
symptoms of the disease and the associated renal lesions, for in 
such cases albuminuria is always present in the urine, together 
with tube-casts, epithelium, blood, and the morphological ele- 
ments common to acute nephritis. In addition to this, all the 
usual phenomena of uraemia follow in most of such cases, but 
especially coma. The urea is greatly diminished ; sometimes it 
is totally absent. The uric acid is also greatly diminished, and 
is even said to be absent in some cases. 

Typhus Fever. — The volume of urine is gradually, though 
not profoundly, diminished up to the third week of this disease. 
The color is increased up to the*crisis, after which it becomes 
normal, and during convalescence it is lighter than in health. 
The reaction of the urine is sharply acid. The urine may remain 



322 URINARY DIAGNOSIS. 

practically free from deposit, although about the crisis a deposit 
of urates is frequent. The quantity of uric acid is increased, 
though less marked, and less uniformly so than urea. The most 
notable feature of the urine, however, in typhus is the marked 
reduction in the quantity of chlorides, which in severe cases 
practically amounts to complete absence or retention. This is 
not due to diarrhoea, lack of food, or other readily explainable 
cause, but seems a constant feature of the disease itself. 

The urine in typhus is frequently albuminous, perhaps more 
frequently so than in typhoid, although there is some difference 
of opinion upon this point. Most are agreed, however, that in the 
more severe forms of the disease albuminuria is the rule. The 
quantity of albumin in the urine varies much, but is frequently 
in large amount in serious cases ; appearing usually toward the 
crisis of the disease, most often on or about the sixteenth day. 

Diseases of the Liver. 

Cirrhosis. — The quantity of urine is constantly diminished in 
cirrhosis of the liver, so constantly indeed that a copious flow 
of urine may be considered strongly presumptive evidence of the 
absence of this disease. Diuretics act with difficult}^ or fail to 
be effective until the congestion of the liver be modified by mer- 
curials or purgatives, and it is in such cases that calomel acts as 
a diuretic. The color of the urine is markedly increased, being 
dark, red, brown, and even blackish. The acidity of the urine 
is increased, and, unlike in pyrexial states, the acidity rapidly 
intensifies after the urine is voided. The dark coloration of the 
urine is due to the presence of bile-pigments in the urine. So 
constant, indeed, is the association of bile-pigment in the urine 
in this disease that it may serve to distinguish ascites of hepatic 
origin from that of peritoneal effusion, especially in non-febrile 
forms of the latter. The excessive bile-pigmentation of the 
urine in cirrhosis of the liver receives its most plausible expla- 
nation in the facts of long detention of the blood in the liver, 
where the red corpuscles are subjected to prolonged meta- 
morphosis. 

The solids of the urine vary widely in quantity in cirrhosis 
of the liver, chiefly in consequence of the great variability of 



DISEASES OF THE LIVER. 323 

the appetite and digestion, the stomach being subject to more or 
less disturbance in these cases through implication with the cir- 
rhotic process. With a normal appetite and digestion the quan- 
tity of urea is subject to little change. On the other hand, the 
quantity of uric acid is pretty uniformly above normal, and 
often very considerably so. The chlorides are somewhat de- 
ficient ; most so in cases attended by ascites, the ascitic fluid 
becoming heavily charged with sodium chloride. Deposits of 
amorphous urates and calcium-oxalate crystals are common. 
Albuminuria is rare, save in cases depending upon valvular 
lesions of the heart. The urinary sediment, as a rule, does not 
contain renal casts and other evidences of nephritis, save in very 
exceptional cases, mostly due to cardiac disease. 

Jaundice. — As a rule, the volume of urine suffers some reduc- 
tion in jaundice, although it is often quite up to the normal 
range. The quantity of urea, as a rule, is diminished ; the uric 
acid is increased ; the sulphates are not especially altered in 
quantity ; hippuric acid is usually absent ; the urine is always 
highly acid, the acidity rapidly intensifying after the urine is 
voided. The color of the urine depends upon the presence of bile- 
pigments, and varies from saffron-yellow to dark greenish brown 
or sometimes porter color. The bile-pigments are sometimes pres- 
ent in the urine in very large quantity, as well as the bile-acids. 
Benzoic acid fails to be eliminated b}^ the urine as hippuric acid, 
contrary to conditions of health. In marked cases sugar some- 
times appears in the urine, and this may be regarded as an 
unfavorable indication. 

The chief value of examinations of the urine in jaundice is 
to establish the diagnosis at an early period. Our present tests 
for bile-pigments enable us to ascertain when the disease is 
coming on, as these products appear in the urine very early. The 
presence or absence of bile-elements, as well as leucin and tyrosin, 
in doubtful cases assists in distinguishing between obstructive 
and non-obstructive jaundice. 

Acute Yellow Atrophy. — This somewhat rare and rapidly -fatal 
disease is attended by marked icterus and by extensive destruc- 
tion of the hepatic cells. The urine is strongly <i<?id in this 
lesion, and contains both bile-pigments and the bile-acids. The 



324 URINARY DIAGNOSIS. 

quantity of the urine is much diminished, though not suppressed, 
and the color is usually very dark brown. The urine usually 
contains leucin or tyrosin or both, the former nearly always, and 
sometimes in very large quantity. The quantity of urea is 
greatly lessened and sometimes nearly absent ; uric acid and 
phosphates are usually reduced in quantity. The urine some- 
times contains albumin and casts, although with no great con- 
stancy, and when casts are present they often appear yellow from 
staining with bile-pigment. 

Articular Diseases. 

Acute Rheumatism. — In rheumatic fever the general features 
of the urine are typically those of pyrexia. The quantity of 
urine is diminished ; the specific gravity is increased, as is also 
the color ; the reaction is sharply acid, and on cooling the urine 
deposits sediments of deeply-colored urates. The quantity of 
solids is increased, but chiefly that of urea. The increase of 
urea usually reaches from 150 to 250 grains above the normal daily 
range. The quantity of uric acid is somewhat increased, though 
to a much less extent than urea. A copious precipitate of urates 
usually occurs at or shortly following the crisis of the disease, 
and as convalescence becomes established this tendency subsides. 
The chlorides are subject to a considerable reduction in quantit}', 
though not to so extreme a degree as in pneumonia. The return 
of chlorides is comparatively early, usually as soon as the tem- 
perature declines to 100° F. and the joint-swellings begin to sub- 
side. The sulphates are increased in quantity to a marked 
degree, usually reaching double the normal range. In acute 
rheumatism and pneumonia the blood contains a marked excess 
of fibrin, and these two diseases furnish the most marked exam- 
ples of increase of sulphates in the urine of all acute fevers. The 
quantity of phosphates in the urine is not materially altered in 
acute rheumatism. 

Albumin often appears in the urine in small amount, but it is 
usually transient. Exceptionally it occurs in marked quantity, 
attended by nephritis. In such cases, morphological elements 
are found in the urinary sediment characteristic of nephritis. 
The kidneys, however, are less frequently, as well as less pro- 
foundly, affected than in pneumonia. 



ARTICULAR DISEASES. 325 

Acute Gout. — Before the attack of gout, or, in other words, 
between the paroxysms, the urine is more or less deficient in 
solids, especially those of uric acid, urea, extractives, and phos- 
phates. In the case of uric acid the reduction is greatest im- 
mediately before the attack, when it may, indeed, be totally 
absent. The same thing occasionally occurs in chronic gout 
during the formation of tophaceous deposits. 

During the attack the volume of urine diminishes more or 
less markedly. Exceptions to this rule occur in cases character- 
ized by chronicity. The frequent co-existence of cardiac hyper- 
trophy and early renal cirrhosis in chronic gouty subjects fur- 
nishes the key to the solution of the occasional poly uric form 
of gout, as well as those exceptional cases attended by deficiency 
of urea in the urine. As a rule, the excretion of urea is not 
materially altered during the paroxysm of gout. Garrod first 
pointed out the now well-known fact that the urine is greatly 
deficient in uric acid in gout ; and this applies both to the attack 
and the intervals between the paroxysms. Sir William Roberts, 
pursuing the chemistry of the subject further, has shown 1 that 
the uric acid is retained and precipitated in the tissues in a state 
of combination as biurate„ The urinary pigment, on the whole, 
is somewhat deficient in gout. Exceptions to this occur in cases 
attended by pyrexia. The phosphates of the urine are markedly 
deficient, notably those of sodium, which doubtless goes to make 
up the tophaceous deposits in the joints. The sulphates are not 
essentially altered in quantity. 

The urine frequently contains albumin, nearly always in 
minute quantity, and sometimes it is a permanent condition. 
Casts are often to be seen in the urine, nearly always of the 
small, narrow, hyaline order. These features are usually the 
result of accompanying cirrhosis of the kidney, which is very 
frequent in gout. Crystals of calcium oxalate are frequent 
features of the urinary sediment. In chronic gout this same 
deficiency of uric acid occurs throughout, though more intermit- 
tently so. 

1 Croonian Lectures for 1892. 



326 urinary diagnosis. 

Diseases of the Nervous System. 

Epilepsy. — In the intervals between the epileptic seizures 
observations thus far have failed to establish any changes of a 
constant character in the urine, although the urea, uric acid, 
chlorides, and phosphates have been claimed to be diminished. 
Immediately succeeding the attacks the volume of the urine is 
often markedly increased, of pale color, of low specific gravity, 
feebly acid in reaction, and sometimes contains albumin, more 
rarely sugar. During and immediately succeeding the attacks 
the urea and phosphates are increased and deposits of urates 
and uric acid are common. 

Hysteria. — Perhaps no physical phenomenon is more widely 
known than the marked increase and pale, aqueous appearance 
of the urine during or immediately succeeding an attack of hys- 
teria. The urine resembles precisely that voided after copious 
libations of water. The color is pale, " watery," the specific 
gravity is greatly lessened, the acidity is diminished, and the 
solids are relatively reduced. The quantity of urine voided by 
hysterical patients is sometimes very large ; two or even three 
pints is not at all uncommon at one passage. It is, perhaps, not 
generally or widely known that in hysterical states the urine is 
sometimes totally suppressed. Laycock was the first to point 
out this fact, and more recently Charcot has called special atten- 
tion to this matter, and has recorded a case in which no urine 
whatever was secreted for eleven days. The utmost watchful- 
ness of the patient was ordered, so that deception was not possi- 
ble. The patient suffered much of the time from vomiting, 
and the ejections contained urea. No other serious symptoms 
ensued, and the urine was ultimately re-established sponta- 
neously. The author has observed, in cases of hysteria due to 
nervous exhaustion, that the volume of urine for twenty-four 
hours often becomes reduced to 15 ounces or even less, which he 
attributes to the deficient vascular tension and insufficient supply 
of nervous force to the kidne} T s. 

Meningitis. — The urine in meningitis is more or less highly 
concentrated. The specific gravity is accordingly high, but the 
reaction is weakly acid, sometimes alkaline. The phosphates 
are greatly in excess, and are readily precipitated in large 



DISEASES OF THE RESPIRATORY ORGANS. 327 

amount upon boiling the urine. The chlorides are normal or 
slightly increased. The quantity of urea is uniformly above 
normal, the increase usually amounting to 25 per cent, or more. 
The urine usually contains a small quantity of albumin as a 
transient condition. 

Diseases of the Respiratory Organs. 

Pulmonary Tuberculosis. — The urine is subject to considera- 
ble variation in its characters in tuberculosis of the lungs, in con- 
sequence of the numerous incidental complicating conditions 
present, — such as diarrhoea, pyrexia! periods, copious diapho- 
resis or expectoration, — as well as the great variability in the 
quantity of food taken. As a rule, the volume of urine is some- 
what augmented. This is largely due to the increased quantity 
of water consumed, thirst being more or less constant in conse- 
quence of the pyrexia. During attacks of diarrhoea the volume 
of urine decreases temporarily, often to 30 ounces and sometimes 
even to 15 ounces. The same decrease precedes a fatal termina- 
tion of the disease. If the appetite remain good, and the disease 
be proceeding without marked disturbing features, the urea re- 
mains about normal in quantity, perhaps slightly below. Dur- 
ing marked hectic the quantity of urea diminishes decidedly, 
especially just before the rigors ; after the rigors it rises rapidly 
and reaches its highest excretion about an hour before the sweat- 
ing stage begins. In cases of intestinal irritation accompanied 
by vomiting, diarrhoea, anorexia, etc., the quantity of urea is sub- 
ject to sudden and decided decrease. Uric acid suffers little, if 
any, reduction ; in fact, it usually rises above the normal range. 
The sulphates are little, if any, affected, — perhaps slightly re- 
duced. The excretion of chlorides varies very much, the varia- 
tion depending chiefly upon the quantity of food taken, the 
degree of pyrexia, and the degree of elimination by the skin and 
bowels. The quantity of pigment varies in phthisical urine 
owing to the disturbing influences of hectic, diarrhoea, and py- 
rexia. A pink sediment is often seen in phthisical urine, es- 
pecially during hectic stages, and the precipitated urates often 
become of a pink or carmine hue. In cases rapidly progressing 
toward a fatal issue the diazo reaction of Ehrlich is sometimes 



328 URINARY DIAGNOSIS. 

obtained in the urine. If this reaction be present for any length 
of time the prognosis may be regarded as unfavorable. 

Albumin is often present in the urine of phthisis, the quantity 
being usually small, except in cases complicated by amyloid 
kidneys. The milder grades of albuminuria are chiefly due to 
impaired nutrition of the renal epithelium, though occasionally, 
perhaps, the result of pyrexia. Renal casts, epithelium, and 
blood are found in the urine exceptionally, the casts chiefly in 
cases complicated by renal lesions, of which amyloid disease is 
the most frequent, and this is usually associated with cases of 
marked chronicity. 

Pneumonia. — The general pyrexial characters of the urine 
are well marked in pneumonia. The quantity of urine is dimin- 
ished one-third to one-half. The quantity of urea is increased, as 
is also uric acid ; the greatest increase occurs on the so-called 
critical days. It is at such times that enormous deposits of 
amorphous urates are so often observable in pneumonia, — more 
marked than in other febrile diseases of equal degree of pyrexia. 
The specific gravity of the urine is increased 1025 to 1035. 
Pigmentation of the urine is markedly increased, which inten- 
sifies the color of the precipitated urates to deep brown, red, or 
even carmine. The increase of pigment often reaches two or 
three times the normal range. 

The chlorides are invariably greatly diminished or absent 
during the early stages and commencing hepatization. This 
deficiency of chlorides continues until convalescence is well 
established, sometimes for several days after, when they re-appear 
in great excess, indicating their retention during the active 
stages of the disease. The absence of chlorides indicates a 
period of danger in pneumonia. The sulphates are uniformly 
increased in pneumonia from one-fourth to one-third above the 
normal range ; only exceptionally do cases occur without being 
attended by this increase. The quantity of phosphates in the 
urine suffers more or less reduction. 

Of the morbid products met with in the urine in pneumonia, 
albumin is by far the most constant, the average being about 45 
per cent, of all cases. Albumin usually appears in the urine at 
the height of the disease, especially during the stage of consoli- 



DISEASES OF THE RESPIRATORY ORGANS. 329 

dation. Its appearance in notable quantity must be looked upon 
as an unfavorable indication ; the death ratio reaches from 45 
to 50 per cent, in such cases, while in non-albuminuric pneumonia 
the death ratio is only about 15 per cent. The fact that albu- 
minuria is so frequent in pneumonia — perhaps as frequent as in 
any other febrile disease — strongly favors the now generally- 
accepted view of the infectious nature of the disease, for albu- 
minuria is now known to be one of the most frequent features 
of infectious fevers. Furthermore, the albuminuria of pneumo- 
nia is evidently independent of the intensity or extent of the 
local pulmonary lesions and of the disturbed function of the 
lungs, since frequently cases of the most extensive consolidation 
and urgent dyspnoea are unattended by albuminuria ; while, on 
the other hand, cases of comparatively mild grade are often 
accompanied by both albuminuria and nephritis. The kidneys 
are often seriously damaged in pneumonia ; the nephritis some- 
times remains comparatively latent throughout convalescence, as 
in scarlatina, to be discovered weeks or months after the pneu- 
monia has subsided, attention being called to the condition 
through uraemia, dropsy, or some of the usual symptoms of 
nephritis. From the above considerations, as might be expected, 
the urine of pneumonia often contains blood, epithelium, casts, 
and the usual products associated with nephritis. The urine 
also contains an excess of mucus, which renders the urine un- 
stable ; hence, the urine in pneumonia possesses a decided ten- 
dency toward alkaline decomposition, and its reaction quickly 
becomes alkaline upon standing. 

Exceptionally pneumonia is attended not only by diminished 
volume of urine, but also by decrease of the solids, including 
urea and uric acid. Such cases are almost invariably character- 
ized by delayed convalescence, diarrhceal attacks, and slow re- 
covery. The proportion of solids in the urine is, in fact, one of 
the most trustworthy guides for prognosis in pneumonia, and 
cases attended by diminished excretion never proceed so favor- 
ably as those in which the solids are excessive. 

During convalescence the volume of the urine increases ; the 
quantity of uric acid, urea, and sulphates, previously excessive, 
now gradually diminish to or below the normal range ; while the 



330 URINARY DIAGNOSIS. 

chlorides, previously held back, now increase considerably above 
normal, often, in fact, to an extraordinary degree. 

Acute Pleurisy. — The urine in pleurisy presents the usual 
febrile type, though not so pronouncedly as in pneumonia. The 
volume is reduced; the organic solids are increased, notably 
during pyrexia. Both urea and uric acid are somewhat ex- 
cessive. The chlorides, sulphates, and phosphates are but little 
changed ; sometimes there is a reduction in the quantity of chlo- 
rides, but not to an}- marked degree. Albuminuria is uncommon 
in pleurisy ; sometimes it appears in mild form, but it is usually 
of temporary duration. The urine often contains a very con- 
siderable amount of peptone, especially during the stage of reso- 
lution, when absorption of large serous effusion is in progress. 
Pleurisy presents an example of the fact that intense pain often 
causes but little effect over tissue metamorphosis, since few 
pyrexial states present so little alterations in urine indicative of 
tissue waste as does simple pleurisy. 

Acute Bronchitis. — The urine in bronchitis varies much in 
character in different cases. This, indeed, is to be expected, 
since the grades of the disease are of all degrees, from slight 
catarrh of the large tubes to disease including nearly all the 
small tubes of both lungs, with collapse of the air-cells, to the 
extent of entailing sharp dyspnoea. In the latter case the urine 
approaches the same characters as those in pneumonia. 

In cases of severe diffuse capillary bronchitis accompanied 
by dyspnoea, there is usually a marked diminution of nearly all 
the solid constituents of the urine, more so than perhaps in any 
other disease save cholera. Parkes records the case of a young 
man who, during two days, voided but 294 cubic centimetres of 
urine per day, containing only 244 grains of total solids, 176 
grains of which were urea, 10.8 grains of sulphates, and no chlo- 
rides. There was no albuminuria or symptoms of uraemia, and 
the urine became gradually established as the patient recovered. 
Moos has recorded a similar case in a girl who, during the height 
of the disease, excreted only 9 grammes of urea (139 grains) and 
2 grammes of sodium chloride. The conditions favoring the re- 
tention of chlorides are those interfering with proper aeration of 
the blood, and there is reason to believe that when these con- 



DISEASES OF THE DIGESTIVE SYSTEM. 331 

ditions are extreme the same influence extends to the entire 
solids of the urine. The urine is occasionally albuminous in 
bronchitis, but this condition is nearly always transient ; impli- 
cation of the kidneys being rare. 

Diseases op the Digestive System. 

Under the term "dyspepsia" a number of symptoms are com- 
monly grouped which are often of widely different causation, and 
many of which are only recently becoming understood, notably 
some of the forms associated with auto-intoxication. In chronic 
disorders of the stomach and intestines the urine is often in- 
creased in quantity, of pale color, of lowered specific gravity, 
with a tendency toward alkaline reaction from fixed alkali. In 
consequence of the alkaline tendency of the urine, there is a 
proneness to precipitation of the earthy phosphates, and such 
urine is often turbid from this cause when voided. As a sec- 
ondary consequence, vesical irritation is a common accompani- 
ment which not infrequently leads to the formation of gravel. 
The quantity of urea depends upon the digestive power of the 
stomach. Usually the quantity of urea in the urine is below 
normal, often markedly so ; the quantity of chlorides correspond 
closely with the amount of food taken. 

In disorders of the intestinal tract attended by increased 
albuminous decomposition the urine is apt to contain large 
amounts of so-called indican, and this is especially favored by 
obstinate constipation or obstructive diseases. 

In organic diseases of the stomach and intestines, especially 
if associated with ulcerative changes, the urine often contains 
notable quantities of peptone. A mild type of albuminuria is 
sometimes associated with disorders of the stomach, and it is, 
indeed, remarkable how frequently the so-called functional albu- 
minuria is found associated with disorders of the stomach. In 
such cases, though the albuminuria is persistent, often extending 
over periods of years, it is rare to find casts in the urine or 
other evidences of nephritis. Small quantities of sugar are 
sometimes found in the urine in dj^speptic conditions. Of the 
urinary sediments found in digestive disorders, calcium-oxalate 
crystals and amorphous phosphates are the most common. 



APPENDIX. 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 

The examination of the urine for life-insurance has for its 
object the determination of the presence or absence of diseases 
of the urinary organs which tend to abridge the normal expect- 
ancy of life. As a special field of urinary diagnosis, this has 
grown to very extensive proportions in nearly all civilized 
countries, and, since the interests involved are so important 
and wide-spread, the subject is well deserving of special con- 
sideration. 

The questions involved in the examination of the urine for 
purposes of life-insurance often call for a high order of skill and 
judgment for their accurate determination, and experience has 
demonstrated that the adoption of systematic methods of con- 
ducting the examination not only simplifies the subject, but also 
renders the conclusions reached more trustworthy. It has, there- 
fore, become the custom with many insurance associations to 
furnish certain rules as a guide in conducting examinations of 
the urine, which are intended to cover the more important points 
of information desired. Notwithstanding these precautions, life- 
insurance associations still find a very large percentage of their 
unprofitable risks arise through diseases of the kidneys which 
have escaped detection. It is with a view of contributing to the 
avoidance of such losses, on the one hand, and, on the other, of 
securing to applicants the privileges of life-insurance to which 
they may be fairly entitled, that the following suggestions are 
presented as a guide for medical examiners. 

A due regard for the interests of his company, as well as for 
his own reputation, should prompt the medical examiner to per- 
sonally ascertain that the urine about to be examined has been 
voided by the applicant. Substitutions of healthy urine by un- 

ooo) 



334 APPENDIX. 

healthy applicants are matters of undoubted facts in the history 
of insurance circles, and, though fortunately of infrequent occur- 
rence, the examiner should be on his guard against such possible 
source of imposition. The applicant should be directed to retain 
his urine for, say, two or three hours before presenting himself 
for examination ; and upon his arrival he should be given a clean 
glass vessel and requested to void therein his urine, which is 
always preferably done in the presence of the medical examiner ; 
but if this be impracticable, the temperature of the urine should 
be immediately noted in order to guard against possible imposi- 
tion. This method also secures a perfectly fresh sample of urine 
— always a matter of prime importance — and, moreover, voided 
at a time most desirable for the purpose, viz., after food and 
exercise ; for it should not be forgotten that the urine voided 
on rising in the morning (which it has become somewhat 
the custom to furnish for these purposes) is the least likely to 
contain either albumin or sugar, when these are present in 
minute quantities. 

If the examination of the urine be unsatisfactory, or if there 
be reason to believe that the sample examined be not a fair aver- 
age, it will be advisable to have the whole twenty-four hours' 
product of the kidneys collected, mixed, and measured, and a 
sample of this mixture examined, and compared with a freshly- 
voided sample of the urine. 

Physical Examination of the Urine. 

Having secured a perfectly-fresh sample of the applicant's 
urine, it should be allowed to stand until it cools down to a tem- 
perature of about 75° or 78° F., and careful observation made of 
its appearance and physical characters. If the color be very 
light (watery), it suggests diminished specific gravity, possibly 
hydruria, — diabetes insipidus. Should the color be of decided 
greenish tint, the possible presence of sugar is suggested : 
should the color be unduly increased, — reddish, — excess of 
urates or the presence of blood is inferred; in the first case 
suggesting rheumatic or gouty conditions ; in the latter, cal- 
culi or some organic renal or vesical lesion. The transparency 
or opacity of the urine should be carefully noted : if cloudy, add 



EXAMINATION OP URINE FOR LIFE-INSURANCE. 335 

a few drops of acetic or other acid to a sample in a test-tube, and 
if the urine become perfectly cleared thereby the earthy phos- 
phates in suspension was the cause of the opacity, their suspen- 
sion being due to diminished acidity of the urine, and it suggests 
some such condition as fasting, dyspepsia, or general debility. 
If the opacity of the urine fail to yield to the action of an acid, 
gently warm the upper layers of the urine by holding the test- 
tube over a spirit-flame, and if it now clear the opacity was 
due to suspension of the amorphous urates, the significance of 
which has already been stated. If, however, the urine still re- 
main cloudy after treating it with both heat and acid, the opacity 
is due to the presence of pus, bacteria or cellular elements, and 
the necessity of microscopical examination is suggested for diag- 
nostic purposes. 

The specific gravity of the urine should next be observed by 
the aid of a good instrument, — preferably a Squibb's specific 
gravity instrument (urinometer), — and the range should be near 
1020. If the specific gravity, however, be above 1025, it suggests 
the possible presence of sugar; if below 1018, it is suspicious of 
the presence of albumin, and should lead to further investiga- 
tions in these special directions. 

The chemical reaction of the urine should next be ascertained 
by means of litmus-paper. If found to be very sharply acid, as 
indicated by intense reddening of blue litmus, the possibility of 
the presence of sugar is suggested, since the urine is more 
sharply acid when it contains sugar than in most other con- 
ditions. Should the urine be frankly alkaline in reaction, as 
indicated b}^ decided blue coloration of red litmus-paper, the 
paper should be dried in order to ascertain if the alkalinity of 
the urine be due to fixed or volatile alkali. If the red color 
return upon drying, after having turned blue in contact with 
the fresh^-voided urine, ammonia is present or volatile alkali, 
and this suggests the presence of some chronic inflammatory 
condition of the lower urinary tract, most likely the bladder. If, 
on the other hand, the blue color remain permanent upon drying 
the paper, the urine is alkaline from fixed alkali, and indicates 
unusual alkalescence of the blood, which ma}^ suggest fasting, 
dyspepsia, or vegetarian habits of eating. 



336 APPENDIX. 

A careful survey of the physical characters of the urine, as 
just indicated, will often lead further investigation in certain 
directions, and also lend confirmation to the points brought out 
by further investigations of the urine. But even though all the 
physical characters of the urine be found perfectly normal, the 
urine cannot be positively asserted to be healthy until search 
has been made at least for sugar and albumin, since either or 
both of these may exceptionally be present in small amounts 
without their presence being indicated by a physical inspection 
of the urine. 

Chemical Examination. 

The most simple chemical examination of the urine for pur- 
poses of life-insurance should, at least, include a search for sugar 
and albumin and a quantitative estimation of the urea. 

Albumin. — If the urine contain albumin in large or even 
medium quantity, it will be made apparent by almost any of the 
ordinary tests for albumin in use. When, however, the urine 
contains but minute quantities of albumin, the case is altogether 
different, and the greatest care is absolutely necessary not only 
to be able, in all cases, to positively identify it, but also to inter- 
pret its true significance. To the search for small quantities of 
albumin in the urine, therefore, the following considerations are 
intended chiefly to apply : — 

The urine frequently contains such foreign substances as 
peptone (deutero-proteose), vegetable alkaloids, and oleoresins, 
besides an excess of such normal constituents as mucin and urates. 
With some reagents for albumin the substances just named give 
reactions almost precisely like those due to small quantities of 
albumin in the urine. It is of the utmost importance to be able 
to readily and positively distinguish the presence of albumin in 
the urine from the substances just named. Nothing is really 
more simple than to make such a distinction with due regard 
to chemical laws ; for it consists simply in employing methods 
that give reactions with albumin while they do not give similar 
reactions with the substances named. This, however, has not 
been the method hitherto uniformly recommended, but, rather, 
it has often been advised to surround old and radically faulty 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 337 

methods (some of which have long outlived their usefulness for 
this purpose) by corrections and precautions which render them 
often complex, if not confusing. 

The medical examiner is advised to discard the use of heat as 
a test for minute quantities of albumin in the urine. The author 
has ceased to employ it for such purposes for over ten years, save 
in the form laid down as No. 2, and only thus for confirmative 
purposes, for he has long since become acquainted with more trust- 
worthy and ready methods. The following method of applying 
test No. 4, described in the text (page 74), will be found to be 
simple, rapid, and trustworthy. Into the bottom of an ordi- 
nary test-tube pour from 15 to 30 drops of acetic acid, and to 
this add about double that amount of aqueous solution of potas- 
sium ferrocyanide (1 to 20). Next, add sufficient urine to half 
or two-thirds fill the test-tube. Close the top of the tube with 
the thumb and invert the test-tube three or four times to insure 
thorough mingling of the reagents with the urine, and then 
stand the tube in a good light. In from half a minute to two 
minutes, if albumin be present even in minute traces it will 
come plainly into view in the form of a milk-like turbidity. 
This method will bring albumin to view with great certainty, 
while it will not bring similarly to view an}^ of those substances 
named, which often produce albumin-like precipitates with many 
other tests. 

Since Heller's nitric-acid test has hitherto been somewhat 
popular in insurance circles, it may be proper to here state the 
additional reasons for the author's preference for the ferrocyanic 
test. 

The nitric-acid method of Heller is a ready and excellent 
test in the presence of considerable amounts of albumin in the 
urine. When mere traces of albumin are present, however, it 
requires from twenty minutes to half an hour to bring it to light 
with certainty. In addition to this the reactions of this test 
with mucin, oleoresins, urates, etc., require corrections and pre- 
cautions which demand skillful manipulation and interpretation 
to reach trustworthy results ; and, therefore, the interests both 
of the company and the applicant are best served by the use of 
the simpler and more trustworth3 r methods. The quantit} T of 



338 APPENDIX. 

albumin in the urine is most rapidly determined by the centrifu- 
gal method described on page 83. x 

Significance of Albuminuria. — Having positively identified 
the presence of albumin in the urine, in all cases its true signifi- 
cance should be next traced. 

As a rule, minute quantities of albumin in the urine are less 
likely to be the result of serious disease of the kidneys in young 
people than when met with in people bej^ond middle age. A 
very considerable percentage of such cases in the young belong 
to that class which has been termed physiological or functional 
albuminuria, terms which are meant to indicate that the kidneys 
are not structurally damaged. In such cases, in addition to the 
fact that the subjects are mostly youug, the urine presents certain 
fairly uniform features, viz. : the specific gravity of the urine is 
usually increased to 1025 or above ; albumin is often absent from 
the urine on rising in the morning, but appears plainly after 
exercise, food, or mental excitement ; the urine is free from renal 
casts and significant morphological elements ; and the quantity of 
urea in the urine remains normal. While many such cases con- 
tinue for years without any marked changes either in the urine 
or in the general health of these subjects, yet a certain propor- 
tion of them ultimately develop into serious nephritis. The fact 
that we possess no positive data by means of which we can with 
certainty distinguish the special cases of this class which will 
ultimately terminate unfavorably from those which will pursue a 
favorable course, and, furthermore, since nephritis is more liable 
to arise from slighter causes in these cases than ordinarily, it 
cannot be affirmed that these cases are safe risks. It has been 
suggested by some authorities that these cases might be accepted 
for a limited endowment insurance of, say, five or ten years, but 

1 It has been shown (pages 83 and 84) that the unit of measurement of 
Esbach's albuminometer-tubes, as ordinarily supplied by the dealers, is too large 
(1 gramme) for accurate measurement of small amounts of albumin in the 
urine. Messrs. Eimer & Amend, of 205 and 211 Third Avenue, New York, now 
manufacture and supply these albuminometers, the first three grammes of the 
reading being graduated in tenths of a gramme, which obviates the above-named 
objection. Moreover, these tubes are specially adapted for use with the author's 
electric centrifuge, so that those who prefer Esbach's quantitative method to the 
author's may carry out the test in two or three minutes. 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 339 

the safer course for the company would be delay for sufficient 
time to determine the ultimate course of the case. These ques- 
tions, however, will be determined by the medical director at the 
home office, to whom all the facts and particulars of such cases 
should be carefully reported. 

Traces of albumin are sometimes observable in the urine of 
perfectly healthy people, the reaction being due to dissolved 
morphological elements, and such is most frequently observed 
in women the subjects of leucorrhcea, or in men with slight 
bladder irritation. If such urine be permitted to stand in a 
conical glass for a few hours, or if it be submitted to the centrif- 
ugal apparatus, a deposit, mostly of epithelium and mucous cor- 
puscles, becomes plainly visible to the naked ej r e. The nucleo- 
albumin of these structures becoming dissolved out, often ren- 
ders the urine sufficiently albuminous to cause slight reaction 
in testing if the quantity of epithelium, etc., be abundant. It 
may be necessary, therefore, in the cases of women, to direct a 
vaginal douche to be used previous to voiding the urine for 
examination, while in other cases it may be necessary to quell 
the vesical irritation by medical treatment before passing opinion 
upon the true state of the urine. 

Minute quantities of albumin are often observed in the urine 
of men at and beyond middle age, who not only appear perfectly 
healthy, but who have, as a matter of fact, enjoyed the most 
typical robust health all their lives. Among this class will be 
found the largest number of those cases which have ahvays 
proved so unprofitable to life-insurance associations, through 
concealed or overlooked disease of the kidneys. 

Two features in this class of cases stand out so prominently 
that they are well calculated to mislead the medical examiner, 
viz., (a) the robust general condition of seemingly perfect health 
of the applicant and (b) the minute (often doubtful without careful 
testing) traces of albumin in the urine often accompanying these 
cases. These facts teach us two highly-important lessons which the 
medical examiner would do well to remember: 1. That a health}" 
appearance or health}' personal record of the subject carries less 
weight, in reaching conclusions as to certain pathological con- 
ditions of the kidneys, than in any other disease. 2. That the 



340 APPENDIX. 

presence of traces of albumin in the urine, however minute, are 
often the index of irretrievably-damaged kidneys. 

Chronic interstitial nephritis, or so-called chronic Bright 's 
disease, to which the foregoing facts especially apply, is nearly 
always the outgrowth and sequel to robust life, the kidnej's 
being the first organs to fail under the stress of long-continued 
functional activity in eliminating the waste-products, which are 
always excessive in people of large appetites and ample nourish- 
ment. These cases present the following typical features : The 
subjects are, as a rule, over 40 years of age; usual history of 
robust health ; appetite always good, often heavy ; and the food 
has consisted largely of meat and highly -nitrogenous products. 
These people usually rise regularly at night — once, twice, or 
oftener — to void their urine, which, to all appearance, is normal 
and free from sediment. The urine, however, is usually of 
lowered specific gravity, — 1018 to 1014. — more or less deficient 
in urea, and contains a small amount — often mere traces — of 
albumin. Microscopical examination merely shows the presence 
of a few small, perfectly hyaline casts. The pulse is always full, 
hard, and unresisting to the finger, — almost characteristically 
so ; the second sound of the heart is abnormally loud, and in 
many cases enlargement of the heart is plainly to be observed. 
If the above-named points be kept in view, the medical examiner 
will have no difficulty in recognizing this dangerous class of 
risks. 

Sugar. — In searching for sugar in the urine, it is of prime 
importance to have on hand some trustworthy and stable 
test that may be depended upon when required. Fehling's 
solution has been much depended upon, but its well-known 
instabilit}^ greatly detracts from its usefulness for the purposes 
under consideration. Fehling's solution will not keep, for 
reasons explained (page 109), and its preparation requires some 
time and pains. A better test, more simple in preparation 
and sufficiently stable that it may be kept on hand for months 
without impairment of its qualities for testing, is that devised 
by Professor Haines (page 103). This test, if properly manip- 
ulated, will yield as trustworthy results as it is possible for any 
copper test to give. 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 341 

In searching for sugar with Haines's test, 1 drachm of the 
test-solution, in an ordinary test-tube, should be raised to the 
boiling-point over a spirit-lamp, and the suspected urine should be 
added, drop by drop, until 8 or 10 drops are added, but not more. 
The test should now be boiled for about half a minute, and, if 
sugar be present, a copious yellow or yellowish-red precipitate 
will suddenly appear throughout the whole mixture. If no such 
reaction take place, sugar is absent. The chief feature in the 
manipulation to be kept in mind is not to add more than the 
stated limit (8 or 10 drops) of urine. If this be disregarded and 
the urine be added (as in Fehling's test) to a volume equal to the 
test-solution, or thereabout, any urine may cause reaction when 
sugar is absent. This is due to the fact that normal urine con- 
tains certain substances (chiefly uric acid, creatinin, etc.) which 
possess feebly reducing powers over copper tests; and, there- 
fore, if the urine be added in excess the test is liable to respond 
to these agents. 

In exceptional cases the urine may contain an excess of 
uric acid or other reducing substances just named, or such 
foreign elements as tannin, carbolic acid, or vegetable alkaloids, 
which may cause slight reaction with this or any copper test. 
For the most part, this reaction is usually an imperfect one, the 
test-solution turning green rather than yellow or red, though 
exceptionally a frank yellow precipitate imvy be formed. Such 
cases, however, in reality are very rare, if the test be manipu- 
lated as directed. Should any doubts, however, arise as to the 
presence of sugar, after thorough cleansing of the test-tube and 
carefully repeating the test in all particulars, as directed, an 
appeal may be made to the phenylhydrazin test, as described 
(page 105), which may be considered conclusive. Having identi- 
fied the presence of sugar in the urine, its exact quantity may 
be readily and rapidly determined by the author's method, 
already described in the text (page 110). 

Significance of Sugar in the Urine. — The presence of sugar 
in the urine, in a general sense, is nowise less serious in its 
signification than is that of albumin. As in the case of albumin, 
the tendency has been to look upon small quantities of sugar in 
the urine as of no grave import ; but recently this view of the 



342 APPENDIX. 

subject is giving way to a belief that, as a rule, the presence 
of sugar in the urine, regardless of the quantity, means serious 
defect, either in the brain or the liver, or in both, and this view 
will prove the safer one to follow. It is true that in a few con- 
ditions, notably in some forms of indigestion, as well as over- 
ingestion of highly-saccharine or amylaceous foods, small quan- 
tities of sugar may appear in the urine in the absence of a 
diabetic state. On the other hand, genuine diabetes mellitus is 
often preceded for a time by precisely these symptoms, viz. : 
the appearance of small quantities of sugar in the urine, often, 
indeed, intermittent, but always aggravated by indulgence in 
saccharine or starchy foods. The author is unable to identify 
the special cases of the former class which subsequently do or 
do not terminate in diabetes, but he is able to affirm, from observa- 
tion, that many of these cases of so-called " digestive glycosuria " 
end in fatal diabetes, more especially in young subjects. It has 
been truthfully said, by an author of wide experience on this 
subject, that "a man with sugar in his urine is like a house that is 
undermined ; he will surely fall, but no one can predict the pre- 
cise time that the disaster will occur." It will be safer to accept 
this assertion as a guide in such cases. 

Urea. — An examination of the urine can scarcely be con- 
sidered complete which does not include an estimate of the 
quantity of its contained urea. Representing, as it does, \>y far 
the greater bulk of the organic output of the kidney's, the quan- 
tity of urea in the urine becomes a valuable index of the func- 
tional capacity of the kidneys, and, therefore, serious forms of 
disease of these organs is usually quickly and markedly reflected 
in the diminished excretion of urea. 

The estimation of urea in the urine is now a matter of such 
simplicity and rapidity that it ranks among the more simple 
manipulative methods, such as testing for albumin and sugar, 
and, in reality, requires but little more time. The method best 
suited for the purposes under consideration is that known as the 
hypobromite test, which is most readily performed with Dr. 
Doremus's ureometer. A fresh solution of sodium lrypobromite 
is necessary for testing, as the solution does not keep well. This 
is best obtained as follows : Have on hand a quarter- or half- 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 343 

pound bottle of bromine, and, after once opened with care, set it 
aside for use. Next prepare a solution of sodium hydroxid 
(caustic sodium) by dissolving 3 ounces of caustic sodium (in 
sticks) in 8 ounces of distilled water, which may also be kept 
on hand for use. In preparing the solution of sodium hypo- 
bromite for testing, pour 10 cubic centimetres of the caustic- 
sodium solution into a graduated glass, and with the pipette 
(furnished with the ureometer) take up 1 cubic centimetre of 
bromine 1 and mix thoroughly with the caustic-sodium solution ; 
next add an equal volume of water, and, after thorough^ 
mixing until the solution becomes fransparent, fill the bulb 
of the ureometer with the solution, and incline the instru- 
ment until the hypobromite solution fills the long arm. Next 
thoroughly cleanse the pipette, and take up 1 cubic centimetre 
of the urine and slowly discharge it into the hypobromite solu- 
tion, in such position that the disengaged nitrogen-gas will all 
ascend the long arm of the instrument, where it is measured. 
As soon as the urea is all decomposed, as indicated by no further 
ascending of bubbles, read off the quantity as indicated by the 
amount of nitrogen-gas marked on the long arm of the instru- 
ment. Each number represents the fractions of a gramme of 
urea per cubic centimetre of urine, of which 0.02 is the normal 
proportion. If preferred, these ureometers are furnished with a 
scale indicating the number of grains of urea per ounce of 
urine instead of grammes per cubic centimetre. 2 

The normal quantity of urea is about 512 grains in twenty- 
four hours for a man of 145 pounds weight, upon a mixed diet 
and moderate amount of exercise. This gives an approximate 
proportion of 10 grains of urea per ounce of urine, the whole 
quantity of the urine being 50 ounces. It will be necessary to 
make an allowance of about 25 or 30 per cent, from this standard 
in order to cover variations caused by differences in weight, age, 
diet, and exercise. If, therefore, the gross quantit}^ of urea sink 
below 350 grains (T grains per ounce), there is reason to appre- 

1 Avoid inhaling the strong vapor of the bromine, which is very irritating to 
the air-passages. 

2 These instruments are furnished by Eiruer & Amend, 205 and '211 Third 
Avenue, New York, at moderate cost. 



344 APPENDIX. 

bend the presence of some organic disease of the kidneys. 
Should the deficiency be still more marked, the quantity of urea 
diminishing to 250 or 200 grains (5 grains per ounce), it fur- 
nishes strong evidence of diseased kidneys. On the other hand, 
a normal amount of urea in the urine, coupled with the absence 
of albumin therefrom, strongly indicates that the kidneys are 
healthy. Certain it is that no very advanced renal disease can 
be present under such circumstances. 

Microscopical Examination. 

A microscopical examination of the urine is often required 
of the medical examiner in cases of applications for heavy 
amounts of insurance. In addition to this, in cases in which a 
chemical examination of the urine has not been conclusive, a 
microscopical investigation should be made. It is not proposed 
to here enter into the technique of microscopy, which every one 
has access to in the numerous works especially devoted to the 
subject. A few general suggestions in reference to the special 
subject herein considered may, however, be of use. 

The urine for microscopical examination should in all cases be 
freshly voided, and it is better to have it somewhat concentrated 
by directing the applicant to abstain from the use of fluids for a 
few hours previous to voiding the urine for examination. Where 
practicable, the sediment is preferably obtained by the centrifu- 
gal method. Should the centrifugal apparatus not be available, 
proceed by adding 10 grains of resorcin, chloral hydrate, or 
salic} 7 lic acid to the urine, in a conical glass, to preserve it from 
change, and, after covering the glass, stand it aside for from 
twenty-four to forty-eight hours, until the sediment subsides. 
Then take up from 4 to 6 drops of the sediment, by means of a 
nipple pipette, from the bottom of the deposit, and place them 
in a shallow cell ; cover the cell with a cover-glass, take up the 
overflow of urine with the torn edge of a piece of blotting- 
paper, place the slide under the microscope, and examine delib- 
erately with a one-fourth-inch objective, avoiding too brilliant 
illumination of the field, since too much light tends to render 
hyaline casts invisible, as they are feebly refractive. Careful 
search should be made over at least two slides prepared as above 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 345 

directed, noting the presence and relative number of pus- or 
blood- corpuscles, but more especially the presence, number, and 
characters of any renal casts. If no pathological products be 
found after examination of two slides, the evidence may be 
considered conclusive in the negative. 

Pyuria. 

The medical examiner will encounter but little difficulty in 
detecting the presence of pus in the urine of the applicant if it 
be present in anj T notable quantity. Such urine is always more 
or less cloudy when voided, and the turbidity does not clear up 
by the addition of an acid or the application of heat ; on the 
contrary, the cloudiness is rather increased by these agents. A 
sediment, more or less pronounced, quickly settles to the bottom 
of the vessel, and if the urine be decanted from the sediment 
and liquor potassse added to the latter, it thickens into a jelly- 
like consistence, and becomes ropy and sticlrv, as will be 
observed in pouring it from the vessel. Should any doubts 
arise, however, as to the nature of this deposit, the microscope 
will readily reveal the presence of characteristic corpuscles, 
described in the text (page 180). 

The significance of pyuria ma} 7 be very grave ; it can scarcely 
ever be considered trivial, inasmuch as it points to bacterial 
infection of the urinary tract. In people beyond middle age it 
is nearly always a serious matter, since in such people the resist- 
ing powers of the system against pyogenic germs are much 
diminished, and consequently the infection under such circum- 
stances is more likely to extend than to subside. Moreover, the 
causes which most often provoke pyuria in elderly people are 
of a permanent nature. 

On the other hand, pyuria in younger subjects is often the 
index of tubercular pyelitis, pyonephrosis, etc., which are not 
only, as a rule, incurable diseases, but often rapidly fatal ones. 
Pj'uria in its least serious signification is the associate of 
mild forms of cystitis in otherwise healthy subjects, and as 
such it is usually soon recovered from, in young or even middle- 
aged subjects, under properly-directed treatment. On the 
whole, p3 r uria should be looked upon as more or less serious, 



346 APPENDIX. 

and the only safe course to pursue in these cases is to recommend 
delay of the application for a few weeks until it be determined 
if the condition be a permanent one. 

HEMATURIA. 

Application will scarcely be made for life-insurance if blood 
be present in the urine in sufficient amount to attract the atten- 
tion of the applicant. Should such be the case, however, the 
examiner will not be likely to overlook cases of pronounced 
hematuria, as they will be apparent upon the most superficial 
inspection of the urine. But the urine may become so highly 
colored from concentration as to conceal minute quantities of 
blood; or, again, blood may be present in quantities so minute 
that it merely lends to the urine a deep shade of normal colora- 
tion. Close inspection will usually distinguish the abnormal 
tint due to blood, and upon standing the distinction will usually 
be more marked in the sediment. In cases of doubt, however, 
the microscope will readily detect the presence of the blood, in 
quantities however minute it may be present. 

The examiner should always inquire for a history of attacks 
of hematuria, with the circumstances associated therewith. The 
appearance of blood in the urine, occurring at irregular intervals, 
often indicates the presence of gravel, or the beginning of such 
still more serious diseases as renal tuberculosis and cancer of 
the kidney. If hematuria has appeared, inquiries should b& 
made as to its character, the frequency of the attacks, as well as 
its extent. Thus, if the blood appeared intimately mingled with 
the urine, of dark color, and without clots, it may be concluded 
that its source was renal, and it would be presumptive evidence 
of the presence of more or less serious disease. On 'the other 
hand, if the blood appeared somewhat separate from the urine, 
of a brighter and more arterial tint, and associated with small 
clots, it ma}^ be concluded that it originated from the lower 
urinary tract, most likely the bladder, and further inquiry is 
likely to elicit symptoms of stone, villous growths, early tubercu- 
losis, or even malignant disease. Unless in the early stages of 
the conditions just named, the accompan3'ing S3'mptoms will be so 
pronounced that they could scarcely be overlooked. There is a 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 347 

period, however, in the early stages of most of these diseases, 
in which mild hematuria may be almost the onty symptom 
observable; hence the importance of ascertaining its occurrence. 
It will be a safe rule for the medical examiner to consider a 
subject in danger of serious disease of the kidneys or bladder 
who presents a history of hsematuria, unless five } 7 ears have 
passed since the last appearance of such attacks, the urine 
remaining in the interval in all respects normal. 

Calculi. 

An examination of the urinary organs cannot be considered 
complete without inquiring for an} T attacks of renal colic or the 
passage of calculi b} r the applicant. A number of such attacks 
may have occurred, and even small calculi may exist and be in 
process of growth in the kidneys without any evidence thereof 
being present in the urine. 

The passage of renal calculus, however small, is usually at- 
tended b}' symptoms of so marked and characteristic an order 
that it will be distinctly remembered by the applicant upon in- 
terrogation. The sudden onset of pain in the side without any 
apparent cause ; the intense suffering for some hours, in which 
the pain extends along the course of the ureter, often retracting 
the testicle on the affected side; frequently accompanied by 
nausea, vomiting, cold perspiration, and even some degree of 
collapse, and followed by sudden and complete relief. These 
form a chain of phenomena so pronounced and distinctive that 
they are neither likely to be overlooked by the applicant nor 
misinterpreted by the medical examiner. 

A man ma} r have one or more such attacks, and the symp- 
toms may permanently disappear without calculus lodging and 
developing into calculous disease. Such cases are termed spon- 
taneous recovery ; but it is not safe to class cases in this 
category until at least five j^ears have passed since the last 
attack, the urine remaining constantly free from pus and blood. 
Under the latter circumstances it may be concluded that the con- 
ditions which favored the formation of calculi have passed away. 
If, on the other hand, attacks have been frequent, and especially 
if there have been recent attacks, it nLiy be concluded that the 



348 APPENDIX. 

conditions favorable for the development of calculous disease 
in the urinary tract still continue, and such cases cannot be 
safely recommended for life-insurance. 

From the sum of these considerations the following rules 
may be formulated, as a concise guide in conducting examina- 
tions of the urine and reaching conclusive data as to the con- 
dition of the kidneys and urinary organs in life-insurance : — 

Rules. 

1. Secure a freshly-voided sample of urine for examination, 
preferably after food and exercise, and be certain that the urine 
examined has been voided by the applicant. 

If the examination result in any doubts as to the true con- 
ditions present, procure a sample of a mixture of the whole 
twenty-four hours' product of the kidneys, and also another 
freshly -voided sample of the urine ; examine both of these sepa- 
rately and compare carefully the results. 

2. Carefully observe first the physical characters of the urine, 
more especially : (a) The appearance. If cloudy, ascertain the 
cause, whether due to phosphates, urates, pus, blood, etc. The 
color, whether light (watery) like hydruria, or greenish (diabetic- 
like), or normal straw-yellow, (b) The specific gravity. If 1025 
or above, search for sugar. If below 1020 search for albumin, 
and also ascertain the total amount of urea, (c) The chemical 
reaction. If very sharply acid (possibly diabetic, rheumatic, or 
gouty conditions are present). If alkaline from fixed alkali 
(probably debility, dyspepsia or fasting, or vegetable diet). If 
amnion iacal (cystitis is suggested). 

3. Examine next for albumin with the ferrocyanic test as 
directed. Do not ignore the presence of albumin, however mi- 
nute the quantity may be. If in any doubt as to the presence of 
minute traces, take two perfectly-clean test-tubes half full of the 
suspected urine. To one apply the ferrocyanic test, but to the 
other add no reagent whatever. Stand the two side by side in 
a good light for ten minutes. If they remain alike, albumin is 
absent ; if faint opacity occur in the one with the test, albumin 
is present. 

4. Examine next for sugar with Haines's test as directed. 



EXAMINATION OF URINE FOR LIFE-INSURANCE. 349 

Boil 1 drachm of this test; add 8 or 10 drops of the urine, — no 
more ; boil again half a minute. If sugar be present, a yellow 
or yellowish-red precipitate will appear. If no such precipitate 
appear, sugar is absent. If a gray or whitish precipitate occur, 
it is caused by earthy phosphates, and not sugar. If any doubts 
arise as to the presence of sugar by the copper test, appeal to 
the phenylhydrazin test for confirmation. 

5. An estimation should next be made of the quantity of 
urea in the urine with the Doremus ureometer, but especially if 
the specific gravity of the urine be materially reduced. Should 
the proportion of urea be 25 per cent, below normal, or lower, 
estimate the whole excretion of urea for twentj^-four hours, and 
if below 300 grains report the fact to the home office. 

6. In cases in which a microscopical examination of the urine 
is requested by the company, carefully report the following feat- 
ures of the urinary sediment : (a) The presence, quantit}^ and 
features of pus- or blood- corpuscles, i.e., whether well preserved 
or partly broken down. (6) The presence, number, and charac- 
ters of any renal casts, especially noting their size, whether clear 
or granulated, and if any epithelium or blood-corpuscles are 
seen attached to the casts. 

7. Inquire for a histoiy of attacks of renal colic (passage of 
calculi) or hematuria. Report the number and special features 
of such attacks, especially the severity and length of time they 
may have continued, and the date of the last attack. 



INDEX 



Abnormal urine, 67 
Acetonuria, 123 
Acute atrophy of liver, 323 
bronchitis, 330 
diffuse nephritis, 247 
gout, 325 

infectious diseases, 315 
interstitial nephritis, 294 
pleurisy, 330 
rheumatism, 324 
Albumin in the urine, 67 
causes of, 68 
determination of, 81-84 
significance of, 68 
tests for, 71-79 
Albuminuria, 67 

clinical significance of, 68 
in life-insurance, 338 
Albumosuria, 84 
detection of, 85 
significance of, 85 
Allantoin in urine, 36 
Ammonio-magnesium phosphate, in 
the urine, 164 
calculi, 220 
Amyloid disease of kidneys, 259 
Analysis of calculi, 224 
Anatomical sediments, in urine, 176 
bacteria, 201 
blood, 176 
cylindroids, 195 
echinococci, 210 
epithelium, 183 
fragments of tumors, 200 
pus, 180 
renal casts, 187 
spermatozoa, 198 
vermes, 206 
Anatomy of bladder, 238 
of kidney, 232 
of renal pelvis, 237 
of ureters, 237 
Animal gum in urine, 48 
Appendix, 333 

Aromatic substances in urine, 39 
Articular diseases, 324 

Bacterial casts in urine, 190 
Bacteriuria. 201 



Bile -acids in urine, 127 

detection of, 129 
Bile-pigments in urine, 130 

significance and detection of, 131 
Bladder, benign growths of, 310 

inflammation of, 301 

malignant disease of, 309 

stone in, 305 

tuberculosis of, 307 
Blood, in the urine, 176 

casts in urine, 188 
Bronchitis, the urine in, 330 

Calcium- carbonate gravel, 221 
oxalate calculi, 218 

sediments, 160 
phosphate calculi, 219 
Calculi, 213 
ammonio-magnesium phosphate, 

220 
analysis of, 224 
calcium- carbonate, 221 
oxalate, 218 
phosphate, 220 
cystin, 218 

differentiation of, 222 
fatty, 221 
indigo, 221 

mixed phosphatic, 220 
prostatic, 221 

relations to life-insurance, 347 
uratic, 217 
uric acid, 215 
Cancer, renal, 269 

vesical, 309 
Cane-sugar in urine, 121 
Carbohydrates in urine, 48-99 
Carbonates of normal urine, 62 
Carbonic gas in urine, 63 
Casts in the urine, 187 

search for, 196 
Centrifugal analysis of urine, 63 
author's method, 64 
for chlorides, 64 
for phosphates, 65 
for sulphates, 65 
Centrifugal sedimentation of urine, 

148 
Centrifuge, the author's electric. 149 

(351) 



352 



INDEX. 



Changes in urine on standing, 5 
Chemical reaction of urine, 14 
Chemical sediments, in urine, 154 
cystin, 168 
fat, 174 

leucin and tyrosin, 170 
melanin, 173 
oxalates, 160 
phosphates, 164 
urates, 157 
uric acid, 154 
Chlorides in the urine, 50 
Cholera, urine in, 318 
Choluria, 127 
Chronic diffuse nephritis, 251 

interstitial nephritis, 254 
Chyluria, 280 

clinical features of, 283 

urine in, 281 
Cirrhosis of kidney, 254 

of liver, 322 
Clinical symptoms of acute diffuse 
nephritis, 250 

of acute interstitial nephritis, 295 

of acute renal hyperemia, 244 

of amyloid kidneys, 262 

of calculus and gravel, 222 

of cancer of the bladder, 310 

of chronic diffuse nephritis, 254 

of chronic interstitial nephritis, 
258 

of chyluria, 283 

of cystic disease of kidneys, 264 

of cystitis, 304 

of diabetes insipidus, 284 

of diabetes mellitus, 286 

of hemoglobinuria, 280 

of hydronephrosis, 291 

of movable kidney, 300 

of passive renal hyperemia, 246 

of pyelitis, 298 

of pyonephrosis, 293 

of renal calculus, 273 

of renal cancer, 270 

of renal embolism, 275 

of renal tuberculosis, 268 
Collection of urine for analysis, 6 
Color of urine, 7 

Composition of normal urine, 4-21 
Consistence of urine, 12 
Creatin and creatinin in urine, 37 
Cylindroids in the urine, 195 
Cystic disease of kidney, 263 
Cystin calculus, 218 
Cystinuria, 168 
Cystitis, 301 



Decompositional changes in urine, 5 
Detection of acetone in urine, 124 
of albumin in urine, 71 
of albumose in urine, 85 
of allantoin in urine, 37 
of bile-acids in urine, 129 
of bile-pigments in urine, 131 
of cane-sugar in urine, 121 
of carbonates in urine, 62 
of chlorides in urine, 51 
of creatin and creatinin in urine, 

38 
of diacetone in urine, 126 
of fibrin in urine, 96 
of globulin in urine, 90 
of glycuronic acid in urine, 121 
of haemoglobin in urine,- 94 
of hippuric acid in urine, 40 
of indoxyl potassium sulphate in 

urine, 44 
of inosite in urine, 119 
of lactose in urine, 118 
of levulose in urine, 118 
of mucin in urine, 50-98 
of normal urobilin in urine, 46 
of oxybutyric acid in urine, 136 
of peptone in urine, 88 
of phenol-potassium sulphate in 
% urine, 43 
of phosphates in urine, 57 
of sugar in urine, 101 
of sulphates in urine, 59 
of urea, 24 
of uric acid, 32 
of xanthin, 36 
Determination of albumin in urine, 

81 
of allantoin in urine, 37 
of bile-acids in urine, 130 
of carbonates in urine, 62 
of chlorides, total, in urine, 52 

centrifugal method, 64 
of creatinin in urine, 38 
of globulin in urine, 90 
of hippuric acid in urine, 40 
of phenol-potassium sulphate in 

urine, 43 
of phosphates, total, in urine, 

58 
centrifugal method, 65 
of sugar in the urine, 107 
of sulphates, total, in urine, 59 

centrifugal method, 65 
of urea, 24 
of uric acid, 33 
Deutero-albumose in the urine, 86 



INDEX. 



353 



Diabetes insipidus, 283 
symptoms of, 284 
urine in, 283 
Diabetes mellitus, 284 
symptoms of, 286 
urine in, 285 
Diacetic acid in urine, 125 

detection of, 126 
Diaceturia, 125 

significance of, 126 
Diagnosis of acute diffuse nephritis, 
247 
of acute interstitial nephritis, 294 
of acute renal hyperemia, 243 
of amyloid kidneys, 259 
of benign growths in bladder, 

310 
of cholera, 318 
of chronic diffuse nephritis, 251 

interstitial nephritis, 254 
of chyluria, 280 

of cystic disease of kidneys, 263 
of diabetes insipidus, 283 
of diabetes mellitus, 284 
of hemoglobinuria, 278 
of hydronephrosis, 290 
of passive renal hyperemia, 245 
of pulmonary tuberculosis, 327 
of pyelitis, 295 
of pyonephrosis, 292 
of renal calculus, 271 
cancer, 269 
embolism, 274 
misplacements, 298 
tuberculosis, 266 
of uraemia, 275 
of vesical cancer, 309 
inflammation, 301 
stone, 305 
tuberculosis, 307 
Diastase in the urine, 49 
Diazo reaction in urine, 134 
Diffuse nephritis, acute, 247 

chronic, 251 
Digestive system, urine in diseases 

of, 331 
Diphtheria, urine in, 320 
Diseases of liver, urine in, 322 
of nervous system, urine in, 326 
of respiratory organs, urine in, 
327 
Distoma haematobium in urine, 206 

Echinococci in urine, 210 
Epilepsy, urine in, 326 
Epithelial casts, 189 



Epithelium in urine, 183 

significance of, 186 
Ethereal sulphates in urine, 41 
Examination of urine for life- 
insurance, 333 

Fatty acids in urine, 48 

casts in urine, 192 

concretions in urine, 221 

deposits in urine, 174 
Ferments in the urine, 49 
Fibrinuria, 95 

Filaria sanguinis hominis, 208 
Fragments of growths in urine, 200 

Gases in the urine, 63 
Globulinuria, 89 

significance of, 89 
Glycero-phosphoric acid in urine, 

48 
Glycogen in the urine, 122 
Glycosuria, 99 

significance of, 100 
Glycuronic acid in urine, 120 

significance of, 121 
Gout, acute, urine in, 325 
Granular casts, 190 
Gravel, ammonio-magnesium-phos- 
phate, 220 

analysis of, 224 

calcium- carbonate, 221 
oxalate, 218 
phosphate, 220 

cystin, 218 

differentiation, clinical, 222 

fatty concretions, 221 

indigo concretions, 221 

mixed phosphatic, 220 

prostatic concretions, 221 

uratic, 217 

uric acid, 215 

xanthin, 219 

Haematuria, 176 

in life-insurance examinations, 
346 

significance of, 177 
Haemoglobin in the urine, 92 

detection of, 94 
Haemoglobinuria, 278 
Hetero-albumose, 86 
Hippuric acid in the urine, 39 
Hyaline casts, 192 
Hydronephrosis, 290 

symptoms of, 291 

urine in, 291 



354 



INDEX. 



Hypersemia, acute renal, 243 

chronic renal, 245 
Hysteria, urine in, 326 

Indigo concretions, 221 
Indoxyl-potassium sulphate (indi- 

can), 43 
Indoxyl-sulphuric acid, 132 
Inorganic constituents of urine, 50 
Inosite, 49 
Inosituria, 119 
Interstitial nephritis, acute, 294 

symptoms of, 295 

urine in, 294 
chronic, 254 

symptoms of, 258 

urine in, 255 
Iron in urine, 63 

Jaundice, urine in, 323 

in acute yellow atrophy, 323 

Kidney, acute diffuse inflammation 

of, 247 
acute interstitial inflammation of, 

294 
amyloid disease of, 259 
anatomy of, 232 
calculus of, 271 
cancer of, 269 
casts of, in urine, 187 
chronic diffuse inflammation of, 

251 
chronic interstitial, inflammation 

of, 254 
cystic disease of, 263 
embolism of, 274 
hydronephrosis of, 290 
hypersemia, acute, 243 

passive, 245 
movable, 298 
pyonephrosis, 292 
tuberculosis of, 266 

Lactosuria, 118 

Leucin deposits in urine, 170 
significance of, 173 

Leucomaines in urine, 136 

Levulosuria, 117 

Life-insurance, examination of urine 
for, 333 
albuminuria, relations of, 336 
calculi, relations of, 347 
collection of urine for, 334 
hematuria, relations of, 346 
microscopical examination of 
urine for, 344 



Life-insurance, pyuria, relations of, 
345 

sugar in urine in, 340 

urea, 342 
Lipuria, 174 

Melanuria, 173 

significance of, 174 
Meningitis, urine in, 326 
Method of testing for albumin, 79 

for sugar, 106 
Micrococcus ureae, 202 
Microscopical examination of urine 

for life-insurance, 344 
Milk-sugar in urine, 48 
Mixed phosphatic gravel, 220 
Movable kidney, 298 
Mucinuria, abnormal, 97 

normal, 49 

Nephritis, acute diffuse, 247 

acute interstitial, 294 

chronic diffuse, 251 

chronic interstitial, 254 
Nitrogen -gas in urine, 63 
Non-pathogenic fungi in urine, 201 
Normal urobilin, 45 

Odor of the urine, 9 

Organic constituents, of the urine, 21 

allantoin, 36 

creatin and creatinin, 37 

diastase, 49 

ethereal sulphates, 41 

fatty acids, 48 

ferments, 49 

glycero phosphoric acid, 48 

hippuric acid, 39 

indoxyl-potassium sulphate 
(indican), 43 

inosite, 49 

milk-sugar, 48 

mucin, 49 

oxalic acid, 47 

pepsin, 49 

phenol-potassium sulphate 
(carbolic acid), 42 

pigments, 45 

rennet, 49 

succinic acid, 48 

trypsin, 49 

urea, 21 

uric acid, 30 

urochrom, 47 

uroerythryn, 47 

xanthin, 36 



INDEX. 



355 



Oxalate-of-calcium sediments, 160 

significance of, 162 
Oxalic acid in the urine, 47 
Oxybutyric acid in urine, 135 
Oxygen-gas in the urine, 63 

Passive hypersemia of kidneys, 245 
Pathogenic fungi in the urine, 203 
Pelvis, renal, anatomy of, 237 
calculi in, 271 
inflammation of, 295 
Peptonuria, 86 

significance of, 87 
Phenol-potassium sulphate in urine 

(carbolic acid), 42 
Phosphates of normal urine, 55 
Phosphatic sediments in urine, 164 

significance of, 166 
Physical characters of urine, 7 
Physical examination of bladder, 
242 

of kidneys, 239 

of ureters, 241 
Pigments of the urine, normal, 45 
Pleurisy, acute, urine in, 330 
Pneumonia, the urine in, 328 
Precipitation of urinary sediments, 
147 

by means of the centrifuge, 148 
Prostatic concretions, 221 
Proteids in the urine, 67 

differential testing for, 91 
Proteoses in the urine, 84 
Ptomaines in the urine, 136 

properties of, 140 
Pulmonary tuberculosis,- 327 

urine in, 327 
symptoms of, 327 
Pus-casts in the urine, 190 
Pus in the urine, 180 

significance of, 182 
Pyelitis, 295 
Pyonephrosis, 292 

urine in, 292 

symptoms of, 293 
Pyrexia, simple, urine in, 313 
Pyuria, 180 

significance of, 182 
in life-insurance, 345 

Quantitative tests for albumin, 81 
for allantoin, 37 
for bile-acids, 130 
for carbonates, 62 
for chlorides, 52 
centrifugal, 64 



Quantitative tests for creatinin, 38 

for globulin, 90 

for hippuric acid, 40 

for phosphates, 58 
centrifugal, 65 

for sugar, 107 

for sulphates, 59 
centrifugal, 65 

for urea, 24 

for uric acid, 33 
Quantity of urine, normal, 15 

Renal calculus, 271 
urine in, 272 
symptoms of, 273 
cancer, 269 
urine in, 269 

symptoms of, 270 
casts in urine, 187 
embolism, 274 
urine in, 274 

symptoms of, 275 
tuberculosis, 266 
urine in, 267 

symptoms of, 268 
Rennet in urine, 49 
Rbeumatism, acute, urine in, 324 
Rules for examiners in life-insur 
ance, 348 

Scarlatina, urine in, 317 
Sedimentation of urine, 147 
Sediments, in the urine, 147 
anatomical, bacteria, 201 

blood, 176 

cylindroids, 195 

echinococci, 210 

epithelium, 183 

fragments of growths, 200 

pus, 180 

renal casts, 187 

spermatozoa, 198 

vermes, 206 
chemical, calcium oxalate, 160 

cystin, 168 

fatty, 174 

leucin and tyrosin, 170 

melanin, 173 

oxalates, 160 

phosphatic, 164 

urates, 157 

uric acid, 154 
Solids of the urine, 16 
Specific gravity of the urine, 12 
Spermatozoa in urine, 198 
significance of, 199 



356 



INDEX. 



Stone, in the bladder, 305 
urine in, 306 

symptoms of, 306 
in the kidney, 271 
urine in, 272 

symptoms of, 273 
Succinic acid in the urine, 48 
Sugar in the urine, 99 
detection of, 101 
determination of, 107 
in life-insurance examinations, 
340 
Sulphates in the urine, 59 

Tests, qualitative, for acetone, 124 

for albumin, 71 

for albumose, 85 

for allantoin, 37 

for bile-acids, 129 

for bile-pigments, 131 

for cane-sugar, 121 

for carbolic acid, 43 

for carbonates, 62 

for chlorides, 51 

for creatinin, 38 

for diacetic acid, 126 

for fibrin, 96 

for globulin, 90 

for glycuronic acid, 121 

for haemoglobin, 94 

for hippuric acid, 40 

for indican. 44 

for inosite, 119 

for lactose, 118 

for levulose, 118 

for mucin, 50-98 

for normal urobilin, 46 

for oxybutyric acid, 136 

for peptone, 88 

for phosphates, 57 

for sulphates, 59 

for urea, 24 

for uric acid, 32 

for xanthin, 36 
Tests, quantitative, for albumin, 
81 

for allantoin, 37 

for bile-acids, 130 

for bile-pigments, 131 

for carbonates, 62 

for chlorides, 52 
centrifugal, 64 

for creatinin, 38 

for globulin , 90 

for hippuric acid, 40 

for indican, 44 



Tests, quantitative, for phosphates, 
58 
centrifugal, 65 
for sugar, 107 
for sufphates, 59 
centrifugal, 65 
for urea, 24 
for uric acid, 33 
Toxic properties of urine, 141 
Transparency of urine, 11 
Trypsin in the urine, 49 
Tuberculosis of bladder, 307 
urine in, 307 

symptoms of, 308 
Tuberculosis of kidney, 266 
urine in, 267 
symptoms of, 268 
Tuberculosis, pulmonary, urine in, 

Tumors, benign, of bladder, 310 
malignant, of bladder, 309 
of kidney, 269 
Tumors, fragments of, in urine, 200 
Typhoid fever, urine in, 315 
Typhus fever, urine in, 321 
Tyrosinuria, 170 
significance of, 173 

Uraemia, 275 
urine in, 275 

Urea, 21 

Uric acid, 30 

Urine, in acute atrophy of liver, 323 
in acute bronchitis, 330 
in acute diffuse nephritis, 247 
in acute gout, 325 
in acute interstitial nephritis, 294 
in acute renal hyperaemla, 244 
in acute rheumatism, 324 
in amyloid kidneys, 260 
in benign growths of bladder, 311 
in calculus of bladder, 306 
in calculus of kidney, 272 
in cancer of bladder, 309 
in cancer of kidney, 269 
in cholera, 318 

in chronic diffuse nephritis, 251 
in chronic interstitial nephritis, 

255 
in chyluria, 281 

in cystic disease of kidneys, 264 
in cystitis, 302 
in diphtheria, 320 
in diabetes insipidus, 283 
in diabetes mellitus, 285 
in embolism of kidney, 274 



INDEX. 



157 



Urine, in epilepsy, 326 
in gout, acute, 325 
in hemoglobinuria, 279 
in hydronephrosis, 291 
in hysteria, 326 
in meningitis, 326 
in movable kidney, 299 
in passive renal hyperemia, 245 
in pleurisy, acute, 330 
in pneumonia, 328 
in pyelitis, 296 
in pyonephrosis, 292 
in renal tuberculosis, 267 
in scarlatina, 317 
in simple pyrexia, 313 
in tuberculosis of bladder, 307 
in tuberculosis, pulmonary, 327 
in typhoid fever, 315 
in typhus fever, 321 
in variola, 320 
in yellow fever, 321 
inorganic constituents, 50 

carbonates, 62 

chlorides, 50 

gases, 63 

iron, 63 

phosphates, 55 

sulphates, 59 
organic constituents, 21 

allantoin, 36 

creatin and creatinin 37 

diastase, 49 

ethereal sulphates, 41 

fatty acids, 48 

ferments 49 

glycero-phosphoric acid, 48 

hippuric acid, 39 

indoxyl-potassium sulphate (in- 
dican), 43 

inosite, 49 

milk-sugar, 48 

mucin, 49 

oxalic acid, 47 

pepsin, 49 



Urine, organic constituents, phenol- 
potassium sulphate (car- 
bolic acid), 42 

pigments, 45 

rennet, 49 

succinic acid, 48 

trypsin, 49 

urea, 21 

uric acid, 30 

urochrom, 47 

uroerythryn, 47 

xanthin, 36 
physical characters of, 7 

chemical reaction, 14 

color of, 7 

composition of, 4 

consistence of, 12 

odor of, 9 

solids of, 16 

quantity of, 15 

transparency of, 11 
Urobilin, normal, 45 
Urochrom, 47 
Uroerythryn, 47 

Variola, the urine in, 320 
Vermes, in the urine, 206 

distoma haematobium, 206 

echinococci, 210 

filaria sanguinis hominis, 208 

strongylus gigas, 211 
Vesical stone, 305 

urine in, 306 

symptoms of, 306 
Vesical tuberculosis, 307 

urine in, 307 
symptoms of, 308 

Xanthin, 36 

concretions of, in urine, 219 

Yellow atrophy of liver, acute, 323 
Yellow fever, urine in, 321 




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CATHELL— Book on the Physician Himself. Page 2. 

DAVIS — Diseases of Lungs, Heart, and Kidneys. Page 2. 

EDINGER— The Structure of the Central Nervous System. Page 3. 

EISENBERG— Bacteriological Diagnosis. Page 3. 

GOODELL — Lessons in Gynaecology. Page 4. 

GRANDIN and JARHAN— Obstetric Surgery. Page 4. 

GRANDIN and J ARH AN— Pregnancy, Labor, and the Puerperal 
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International System of Electrotherapeutics. Page 5. 

IVINS — Diseases of the Nose and Throat. Page 5. 

LIEBIG and ROHE;— Electricity in Hedicine and Surgery. Page 6. 

Jl ANTON— Syllabus of Lectures on Human Embryology. Page 6. 

PURDY— Practical Uranalysis and Urinary Diagnosis. Page 8. 

ROHE— Text=Book of Hygiene. Page 9. 

ROHE— Practical Hanual of Skin Diseases. Page 9. 

SCHRENCK=NOTZING— Suggestive Therapeutics in Psychopathia 
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SHOEIIAKER— Hateria Hedica and Therapeutics. Page 10. 

SniTH— Physiology of the Domestic Animals. Page 10. 

STEWART— Obstetric Synopsis. Page 11. 

YOUNG— Synopsis of Human Anatomy. Page 12. 

KRAFFT=EBING— Psychopathia Sexualis. Page 13. 

RANNEY— Lectures on Nervous Diseases. Page 13. 

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COLTflAN— The Chinese: Their Present and Future. 

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DEMARQUAY— On Oxygen. 

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HUIDEKOPER— Age of the Domestic Animals. 

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International System of Electrotherapeutics. 

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* JOAL — On Respiration in Singing. 

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KEATING and EDWARDS— Diseases of the Heart and 
Circulation in Infancy and Adolescence. 

"With an Appendix entitled "Clinical Studies on the Pulse in Childhood." By 
John m. Keating, M.D., Philadelphia, and William A. Edwards, M.D., Phila- 
delphia. Illustrated by Photographs and Wood-Engravings. About 225 pages. 8vo. 
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KRAFFT=EBING— A Text=Book on Insanity. 

For the Use of Students and Practitioners. By Dr. R. von Krafft-Ebing. 
Authorized translation of the Fifth German Edition by Charles Gilbert Chad- 
dock, M.D., Professor of Nervous and Mental Diseases in Marion-Sims College of 
Medicine, St. Louis, Mo., etc. Royal Octavo. About 800 pages. In Preparation. 

LIEBIG and RO HE— Electricity in Medicine and Surgery. 

By G. A. Liebig, Jr., Ph.D., Assistant in Electricity, Johns Hopkins Uni- 
versity, etc. ; and George H. Rohe, M.D., Professor of Obstetrics and Hygiene, 
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flANTON — A Syllabus of Lectures on Human Embryology. 

An Introduction to the Study of Obstetrics and Gynaecology, with a Glossary 
of Embryological Terms. By Walter Porter Manton, M.D., Lecturer on Ob- 
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MASSEY — Electricity in the Diseases of Women. 

AVith Special Reference to the Application of Strong Currents. By G. Betton 
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With New and Original Wood-Engravings. Extra Cloth. 240 pages. 12mo. 

Price, in United States and Canada, SI. 50, net; Great Britain, 8s. 6d. ; 
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riedical Bulletin Visiting List, or Physicians' Call Record. 

Arranged upon an Original and Convenient Monthly and Weekly Plan for the 
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fllCHENER— Hand=Book of Eclampsia. 

Or, Notes and Cases of Puerperal Convulsions. By E. Michenee, M.D. ; 
J. H. Sttjbbs, M.D. ; R. B. Ewing, M.D. ; B. Thompson, M.D. ; S. Stebbins, 
M.D. 16mo. Cloth. Price, 60 cts., net. Great Britain, 3s. 6d. 

flONTQOMERY— Practical Gynaecology. 

By E. E. Montgomery, A.M., M.D., Professor of Clinical Gynaecology in the 
Jefferson Medical College, Philadelphia, etc., etc. In one Royal Octavo volume. 
Thoroughly Illustrated. In Preparation. 

*M00RE— meteorology. 

By J. W. Moore, B.A., M.Ch., University of Dublin ; Fellow and Registrar of 
the Royal College of Physicians of Ireland, etc. Part I. Physical Properties of the 
Atmosphere. Part II. A Complete History of the United States Weather Bureau 
from its Beginning to the Present Day, specially contributed by Prof. W. M. 
Harrington, Chief of the Weather Bureau in Washington, D.C., giving also a full 
list of all the stations under the immediate control of the United States Government. 
Part III. Weather and Climate. Part IV. The Influence of Weather and Season on 
Disease. Profusely Illustrated throughout. One volume. Crown Octavo. Over 400 
pages. Cloth. 

Price, post-paid, in United States and Canada, 852.00, net ; Great Britain, 
8s. ; France, 9 fr. 50. 

*MYGIND— Deaf-Mutism. 

By Holgee Mygind, M.D., of Copenhagen. The only authorized English 
Edition. Comprising Introduction, Etiology and Pathogenesis, Morbid Anatomy, 
Symptoms and Sequelae, Diagnosis, Prognosis, and Treatment. Crown Octavo. 
About 300 pages. Cloth. 

Price, post-paid, in United States and Canada, 883.00, net; Great 
Britain, 8s. ; France, 9 fr. 50. 

NISSEN — A Manual of Instruction for Giving Swedish 
flovement and Massage Treatment. 

By Prof. Hartvig Nissen, late Instructor in Physical Culture and Gym- 
nastics at the Johns Hopkins University, Baltimore, Md., etc. With 29 Original 
Wood-Engravings. 12mo. 128 pages. Cloth. 

Price, in United States and Canada, 851.00, net ; Great Britain, 6s. ; 
France, 6 fr. 20. 

Physicians' All«Requisite TimeM and Labor** Saving 
AccountMBook. 

Being a Ledger and Account-Book for Physicians' Use, meeting all the Re- 
quirements of the Law and Courts. Designed by William A. Seibert, M.D., of 
Easton, Pa. There is no exaggeration in stating that this Account-Book and Ledger 
reduces the labor of keeping physicians' accounts more than one-half, and at the 
same time secures the greatest degree of accuracy. 

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Physicians' Interpreter. 

In Four Languages, English, French, German, and Italian. Specially arranged 
for diagnosis by M. von V. The plan of the hook is a systematic arrangement of 
questions upon the various branches of Practical Medicine, and each question is so 
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full Russia Leather, for carrying in the pocket. Size, 5x2% inches. 206 pages. 
Price, in United States and Canada, $1.00, net ; Great Britain, 6s. ; 
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PURDY— Diabetes. 

Its Cause, Symptoms, and Treatment. By Chas. W. Puedy, M.D., Honorary 
Fellow of the Royal College of Physicians and Surgeons of Kingston ; Author of 
■Blight's Disease and Allied Affections of the Kidneys" ; Member of the Associa- 
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Price, in United States and Canada, SI. 25, net ; Great Britain, 6s. 6d. ; 
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PURDY — Practical Uranalysis and Urinary Diagnosis. 

A Manual for the Use of Physicians and Students. By Chas. W. Puedy, 
M.D., Author of " Diabetes : its Cause, Symptoms, and Treatment"; Member of the 
Association of American Physicians, etc., etc. With numerous Illustrations, includ- 
ing several Colored Plates. Crown Octavo. About 350 pages. Extra Cloth. 
Price, in United States and Canada, S3. 50, net. Great Britain, 14s. ; 
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REflONDINO— History of Circumcision. 

From the Earliest Times to the Present. Moral and Physical Reasons for its 
Performance ; with a History of Eunuchism, Hermaphrodism, etc., and of the 
Different Operations Practiced upon the Prepuce. By P. C. Remondino, M.D., 
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pages. Extra Cloth. Illustrated with two fine full-page Wood-Engravings, showing 
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REnONDINO— The mediterranean Shores of America. 

Southern California : its Climatic, Physical, and Meteorological Conditions. 
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*ROBINSON and CRIBB— The Law and Chemistry Relating 
to Food. 

A Manual for the Use of persons practically interested in the Administration 
of the Law relating to the Adulteration and Unsoundness of Food and Diugs. By H. 
Mansfield Robinson, LL.D. (London), Solicitor and Clerk to the Shoreditch 

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Sanitary Authority ; Law Examiner for the British Institute of Public Healtk, 
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Strand District, etc. Crown Octavo. About 300 pages. 

Price, in United States and Canada, 882.00, net ; Great Britain, 8s. ; 
France, 9 fr. 50. 

ROHE— Text~Book of Hygiene. 

A Comprehensive Treatise on the Principles and Practice of Preventive Medi- 
cine from an American Stand-point. By George H. Rohe, M.D., Professor of Ob- 
stetrics and Hygiene in the College of Physicians and Surgeons, Baltimore ; Member 
of the American Public Health Association, etc. Third Edition, carefully 
revised and enlarged, with many Illustrations and valuable Tables. Royal Octavo. 
Over 450 pages. Extra Cloth. 

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ROHE— A Practical rianual of Diseases of the Skin. 

By George H. Rohe, M.D., assisted by J. Williams Lord, A.B., M.D., Lect- 
urer on Dermatology and Bandaging in the College of Physicians and Surgeons, 
Baltimore, etc. 12mo. Over 300 pages. Extra Cloth. 

Price, in United States and Canada, $1.35, net; Great Britain, 6s. 6d. ; 
France, 7 fr. 75. 

SAJOUS — Hay Fever and its Successful Treatment, 

By Superficial Organic Alteration of the Nasal Mucous Mem- 
brane. By Charles E. Sajous, M.D., Chief Editor " Annual of the Universal 
Medical Sciences" ; formerly Lecturer on Rhinology and Laryngology in the Jeffer- 
son Medical College, etc. With 13 Engravings on Wood. 12mo. Extra Cloth. 
Price, in United States and Canada, Sl.OO, net; Great Britain, 6s.; 
France, 6 fr. 20. 

*SCHUSTER— When is Harriage Permissible after Syphilis? 

By Dr. Schuster, of Aix-la-Chapelle. Translated from the German by C. 
Renner, M.D., London. 8vo. 32 pages. Price, 25 cents net, or 1 shilling. 

SENN — Principles of Surgery. 

By N. Senn, M.D., Ph.D., Professor of Principles of Surgery and Surgical 
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Chicago Polyclinic, etc. Royal Octavo. With 109 fine Wood-Engravings. 624 pages. 
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SENN — Tuberculosis of the Bones and Joints. 

By N. Senn, M.D., Ph.D., author of a text-book on the "Principles of Sur- 
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of them colored. 

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SHOEMAKER— Heredity, Health, and Personal Beauty. 

Including the Selection of the Best Cosmetics for the Skin, Hair, Nails, and 
All Parts Relating to the Body. By John V. Shoemaker, A.M., M.D., Professor 
of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clini- 
cal Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadel- 
phia, etc. Royal Octavo. 425 pages. 

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SHOEMAKER— Ointments and Oleates, 

Especially in Diseases of the Skin. By John V. Shoemaker, A.M., M.D. 
Second Edition, revised and enlarged. 298 pages. 12mo. Extra Cloth. 

Price, in United States and Canada, $1.50, net ; Great Britain, 8s. 6d. ; 
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SHOEMAKER— flateria fledica and Therapeutics. 

With Especial Reference to the Clinical Application of Drugs. By John V. 
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peutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the 
Medico-Chirurgical College of Philadelphia, etc. Second Edition, Thoroughly 
Revised. In Two Volumes. Royal Octavo. Nearly 1100 pages. The volumes may 
be purchased separately. 

Volume I (354 pages) is devoted to Pharmacy, general Pharmacology and 
Therapeutics, and remedial agents not properly classed with drugs. 

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Volume II (700 pages) is wholly taken up with the consideration of drugs, 
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Therapy. 

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Each volume is thoroughly and carefully indexed with clinical and general 
indexes, and the second volume contains a most valuable and exhaustive table of 
doses extending over several double-column octavo pages. 

SniTH — Physiology of the Domestic Animals. 

A Text-Book for Veterinary and Medical Students and Practitioners. By 
Robert Meade Smith, A.M., M.D., formerly Professor of Comparative Physi- 
ology in University of Pennsylvania, etc. Royal Octavo. Over 950 pages. Profusely 
illustrated with more than 400 fine Wood-Engravings, some of them Colored. 
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SOZINSKEY— fledical Symbolism. 

Historical Studies in the Arts of Healing and Hygiene. By Thomas S. Sozins- 
key, M.D., Ph.D., Author of "The Culture of Beauty," "The Care and Culture of 

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Children," etc. 12mo. Nearly 200 pages. Extra Cloth. Appropriately illustrated 
with thirty (30) new Wood-Engravings. 

Price, in United States and Canada, SI. 00, net ; Great Britain, 6s. ; 
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STEWART— Obstetric Synopsis. 

A Complete Compend. By John S. Stewart, M.D., late Demonstrator of 
Obstetrics in the Medico-Chirurgical College of Philadelphia; with an introductory 
note by William S. Stewart, A.M., M.D., Emeritus Professor of Obstetrics and 
Gynaecology in the Medico-Chirurgical College of Philadelphia. 42 Illustrations. 
202 pages. 12mo. Extra Blue Cloth. 

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STRAUB— Symptom Register and Case Record. 

Designed by D. W. Stratjb, M.D. Giving in plain view, on one side of the 
sheet 7% x 10% inches, the Clinical Record of the sick, including Date, Name, Resi- 
dence, Occupation, Symptoms, Inspection (Auscultation and Percussion), History, 
Respiration, Pulse, Temperature, Diagnosis, Prognosis, Treatment (special and 
general), and Remarks, all conveniently arranged, and with ample room for record- 
ing, at each call, for four different calls, each item named above, the whole forming 
a clinical history of individual cases of great value to every Practitioner. 

Published in stiff Board Tablets, of 50 sheets each, at 50 cents, net, per 
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*THRESH— Water Supplies. 

By J. C. Thresh, D.Sc.Lond., M.B., F.I.C., F.C.S., Lecturer in Sanitary 
Science, King's College, London, etc. City Authorities, Town Councils, Levy 
Courts, County Councils, Farmers, Owners of Villas or Private Residences in the 
Country, Settlers in newly-opened Districts, Colonists, etc., will find this little book 
of extreme value, as it contains practical hints with excellent illustrations by the 
score. Illustrated. One Volume. Crown Octavo. About 300 pages. Cloth. 

Price, in the United States and Canada, $3.00, net ; Great Britain, 8s. ; 
France, 9 fr. 50. 

transactions of the fleetings of the British Laryngological 
Association. 

Volume I, 1891. Royal 8vo. 108 pages. Cloth. Price, 3s. 6d. (75 .cents, net). 
Volume II, 1892. Royal 8vo. 100 pages. Cloth. Price, 3s. 6d. (75 cents, net). 
Volume III, 1893. Royal 8vo. 106 pages. Price, 3s. 6d. (75 cents, net). 
The three volumes togethei-, 6s. (S3.00, net). 

ULTZflANN— The Neuroses of the Genito=Urinary System 
in the Hale. 

With Sterility and Impotence. By Dr. Ultzmann, Professor of Genito- 
urinary Diseases in the University of Vienna. Translated, with the author's per- 
mission, by Gardner W. Allen, M.D., Surgeon in the Genito- Urinary Depart- 
ment, Boston Dispensary. Illustrated. 12mo. Extra Cloth. 

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12 Medical Publications of the F. A. Davis Co., Philadelphia. 



VOUGHT— Chapter on Cholera for Lay Readers. 

History, Symptoms, Prevention, and Treatment of the Disease. By Walter 
Votjght, Pli.B., M.D., late Medical Director and Physician-in-Charge of the Fire 
Island Quarantine Station, Port of New York ; Fellow of the New York Academy .of 
Medicine, etc. Illustrated. 12ino. 106 pages. Flexible Cloth. 

Price, in United States and Canada, 75 cents, net ; Great Britain, 4s. ; 
France, 5 fr. 

WITHERSTINE— International Pocket Medical Formulary. 

Arranged Therapeutically. By C. Sumner Witherstine, A.M., M.D., Vis- 
iting Physician of the Home for the Aged, Germantown, Philadelphia ; late House 
Surgeon to Charity Hospital, New York, etc. Including more than 1800 formulae 
from several hundred well-known authorities. With an Appendix containing a Po- 
sological Table, the newer remedies included ; Formula? and Doses of Hypodermatic 
Medication, including the newer remedies ; Uses of the Hypodermatic Syringe, etc. 
275 printed pages, besides extra blank leaves for new formulae. Elegantly printed, 
with red lines, edges, and borders. Illustrated. Bound in Leather, with Side-Flap. 
Price, in United States and Canada, $2.00, net ; Great Britain, lis. 6d. ; 
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YOUNG — Synopsis of Human Anatomy. 

Being a Complete Compend of Anatomy, including the Anatomy of the Viscera, 
and Numerous Tables. By James K. Young, M.D., Instructor in Orthopaedic Sur- 
gery and Assistant Demonstrator of Surgery, University of Pennsylvania, etc. 
Illustrated with 76 Wood-Engravings. 320 pages. 12mo. Extra Cloth. 

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The following Publications are Sold Only by Subscription, 

or Sent Direct on Receipt of Price, Shipping 

Expenses Prepaid. 

Annual of the Universal Medical Sciences. 

A Yearly Report of the Progress of the General Sanitary Sciences Throughout 
the World. Edited by Charles E. Sajotjs, M.D., formerly Lecturer on Laryn- 
gology and Rhinology in Jefferson Medical College, Philadelphia, etc., and Seventy 
Associate Editors, assisted by over Two Hundred Corresponding Editors and Col- 
laborators. In Five Royal Octavo Volumes of about 500 pages each. Illustrated 
with Chromo-Lithographs, Engravings. Maps, Charts, and Diagrams. Being intended 
to enable any physician to possess, at a moderate cost, a complete Contemporary 
History of Universal Medicine. 

Subscription Price per year (including the " Universal Medical Journal" 
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Russia, $31.00. Great Britain, Cloth, JE4 Ts. ; Half-Russia, £5 15s. 
France, Cloth, 93 fr. 95 ; Half-Russia, 124 fr. 35. 
The "Universal Medical Journal" is a Monthly Review of the practical 
branches of Medicine and Surgery, and is supplied free to the subscribers to the 
"Annual" ; to non-subscribers, $2.00 per year ; Great Britain, 8s. 6d. 

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ADAMS— History of the Life of D. Hayes Agnew, fl.D., LL.D. 

By J. Howe Adams, M.D. A fascinating life-history of one of the world's 
greatest surgeons. Royal Octavo. 376 pages. Handsomely printed, with Portraits 
and other Illustrations. 

Price, in United States and Canada, Extra Cloth, 882.50, net. ; Half- 
Morocco, Gilt Top, $3.50, net. Great Britain, Cloth, 14s. ; Half- 
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KRAFFT=EBING— Psychopathia Sexualis. 

With Especial* Reference to Contrary Sexual Instinct : A Medico-Legal Study 
of Sexual Insanity. By Dr. R. von Krapft-Ebing, Professor of Psychiatry and 
Neurology, University of Vienna. Authorized Translation of the Seventh Enlarged 
and Revised German Edition, by Charles Gilbert Chaddock, M.D., Professor 
of Nervous and Mental Diseases, Marion-Sims College of Medicine, St. Louis. One 
Royal Octavo Volume. 432 pages. 

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RANNEY — Lectures on Nervous Diseases. 

From the Stand-Point of Cerebral and Spinal Localization, and the Later 
Methods Employed in the Diagnosis and Treatment of these Affections. By Am- 
brose L. Ranney, A.M., M.D., formerly Professor of the Anatomy and Physiology 
of the Nervous System in the New York Post-Graduate Medical School and Hos- 
pital, etc. ; Author of " The Applied Anatomy of the Nervous System," " Practical 
Medical Anatomy," etc. Profusely Illustrated with Original Diagrams and Sketches 
iu Color by the author, carefully selected Wood-Engravings, and Reproduced Photo- 
graphs of Typical Cases. Royal Octavo. 780 pages. 

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SAJOUS — Lectures on the Diseases of the Nose and Throat. 

Delivered at the Jefferson Medical College, Philadelphia. By Charles E. 
Sajotjs, M.D., formerly Lecturer on Rhinology and Laryngology in Jefferson Medi- 
cal College ; Vice-President of the American Laryngological Association, etc. Illus- 
trated with 100 Chromo-Lithographs, from Oil-Paintings by the author, and 93 
Engravings on Wood. One handsome Royal Octavo volume. 

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SCHRENCK=NOTZING— Suggestive Therapeutics in Psy- 
chopathia Sexualis. * 

By Dr. A. VON" Schrenck-Notzing, of Munich. Authorized Translation of 
the Latest Revised German Edition, by C. G. Chaddock, M.D. An invaluable sup- 
plementary volume to Dr. R. von Keafft-Ebing's masterly treatise on " Psycho- 
pathia Sexualis " (also translated by Dr. Chaddock). A hand-book of treatment 
of Sexual Pathology upon sound and effective principles. Royal octavo. About 
350 pages. 

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14 Medical Publications of The F. A. Davis Co., Philadelphia. 



STANTON — The Encyclopedia of Face and Form Reading. 

Or Personal Traits, both Physical and Mental, Revealed by Outward Signs 
Through Practical and Scientific Physiognomy. Being a Manual of Instruction in 
the Knowledge of the Human Physiognomy and Organism. By Maby Olmsted 
Stanton, author of "A Practical and Scientific Treatise on Physiognomy" ; "A 
Chart for the Delineation of Mental and Physiological Characteristics," etc. With 
an outline of study, glossary, and classified suggestive questions and elaborate aids 
to the study, together with original articles upon vital subjects by distinguished 
authorities Second Edition, Revised. Profusely illustrated. 

Royal Octavo, over 1300 pages. Cloth, $4.00 ; Sheep or Ha'if-Russia, $5.00. 

* Journal of Laryngology, Rhinology, and Otology. 

An Analytical Record of Current Literature Relating to the Throat, Nose, and 
Ear. Issued on the First of Each Month. Edited by Dr. Norms Wolfenden, of 
London ; Dr. John Macintyre, of Glasgow, and Dr. Dundas Grant. 

Price, 20s. or $5.00 per annum (inclusive of postage). For single copies, 
however, a charge of 2s. 6d. (50 cents) will be made. 

The fledical Bulletin. 

A Monthly Journal of Medicine and Surgery. Edited by John V. Shoemaker, 
A.M., M.D. Articles by the best practical writers procurable. Every article as 
brief as is consistent with the preservation of its scientific value. Therapeutic notes 
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The Universal riedical Journal. 

A Monthly Magazine of the Progress of Every Branch of Medicine in all 
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IN PREPARATION FOR EARLY PUBLICATION. 
Pregnancy, Labor, and the Puerperal State. 

By Egbert H. Grandin, M.D., and George W. Jarman, M.D. Profusely 
illustrated with handsome full-page photographic plates and numerous wood-cuts. 
Royal octavo. A companion volume to " Obstetric Surgery," by the same authors. 
(See page 4.) The two volumes form a complete modern treatise on the Science 
and Art of Obstetrics. 

$W All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



